Healthcare Provider Details

I. General information

NPI: 1659666543
Provider Name (Legal Business Name): JAMES BERWICK, LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2011
Last Update Date: 06/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 22ND ST
ST AUGUSTINE FL
32084-1798
US

IV. Provider business mailing address

505 22ND ST
ST AUGUSTINE FL
32084-1798
US

V. Phone/Fax

Practice location:
  • Phone: 904-599-3602
  • Fax: 904-461-8368
Mailing address:
  • Phone: 904-599-3602
  • Fax: 904-461-8368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW1692
License Number StateFL

VIII. Authorized Official

Name: JAMES BERWICK
Title or Position: OWNER/OPERATOR
Credential: LCSW
Phone: 904-599-3602