Healthcare Provider Details

I. General information

NPI: 1588159420
Provider Name (Legal Business Name): GUADALUPE LUIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2018
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEERFIELD PRESERVE BLVD
ST AUGUSTINE FL
32086-5966
US

IV. Provider business mailing address

6625 ARGYLE FOREST BLVD STE 4
JACKSONVILLE FL
32244-6126
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-0814
  • Fax:
Mailing address:
  • Phone: 904-600-4178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10605-C
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2002029
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-21629
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14105
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC015742
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: