Healthcare Provider Details

I. General information

NPI: 1497594311
Provider Name (Legal Business Name): SRL PROFESSIONAL PRACTICE & BEYOND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MULBERRY ST
ST AUGUSTINE FL
32084-2867
US

IV. Provider business mailing address

14 MULBERRY ST
ST AUGUSTINE FL
32084-2867
US

V. Phone/Fax

Practice location:
  • Phone: 908-256-0282
  • Fax:
Mailing address:
  • Phone: 908-256-0282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHANNON LYNCH
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 908-256-0282