Healthcare Provider Details

I. General information

NPI: 1215260609
Provider Name (Legal Business Name): PATRICIA LEWIS-SLAYTON, LCSW LMFT. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S PONCE DE LEON BLVD STE 1
ST AUGUSTINE FL
32084-6013
US

IV. Provider business mailing address

2112 W. LYMINGTON WAY
ST. AUGUSTINE FL
32084
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7733
  • Fax: 904-829-9768
Mailing address:
  • Phone: 904-824-7733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW1594
License Number StateFL

VIII. Authorized Official

Name: MS. PATRICIA LEWIS-SLAYTON
Title or Position: PSYCHOTHERAPIST
Credential: LCSW. LMFT
Phone: 904-822-7733