Healthcare Provider Details

I. General information

NPI: 1063100089
Provider Name (Legal Business Name): NATHAN DANIEL HENRY MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 S DILLARD ST STE 220B
WINTER GARDEN FL
34787-3596
US

IV. Provider business mailing address

11738 HAMPSTEAD ST
WINDERMERE FL
34786-5724
US

V. Phone/Fax

Practice location:
  • Phone: 407-734-3338
  • Fax:
Mailing address:
  • Phone: 585-943-1623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18250
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: