Healthcare Provider Details

I. General information

NPI: 1689072514
Provider Name (Legal Business Name): CAITLIN ROSE LABRADOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAITLIN ROSE BLOOM MSW, RCSWI

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 201B
ST AUGUSTINE FL
32080-3116
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 201B
ST AUGUSTINE FL
32080-3116
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-5965
  • Fax:
Mailing address:
  • Phone: 904-342-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: