Healthcare Provider Details

I. General information

NPI: 1366544991
Provider Name (Legal Business Name): MARK JAMES CARDILLO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 N PINELLAS AVE
TARPON SPRINGS FL
34689
US

IV. Provider business mailing address

433 4TH ST NORTH
ST PETERSBURG FL
33701
US

V. Phone/Fax

Practice location:
  • Phone: 727-944-5171
  • Fax: 722-944-5174
Mailing address:
  • Phone: 727-895-8499
  • Fax: 727-895-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW4722
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: