Healthcare Provider Details

I. General information

NPI: 1447773270
Provider Name (Legal Business Name): LORI T REASONOVER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 KINGSLEY LAKE DR STE 702
ST AUGUSTINE FL
32092-3045
US

IV. Provider business mailing address

4079 GLENHURST DR N
JACKSONVILLE FL
32224-2297
US

V. Phone/Fax

Practice location:
  • Phone: 904-993-0019
  • Fax: 904-993-0019
Mailing address:
  • Phone: 904-220-6883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14640
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: