Healthcare Provider Details

I. General information

NPI: 1487139440
Provider Name (Legal Business Name): CAROL LUCIUS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 OCEAN DR
DENNIS PORT MA
02639-2214
US

IV. Provider business mailing address

8719 HARPERS GLEN CT
JACKSONVILLE FL
32256-4543
US

V. Phone/Fax

Practice location:
  • Phone: 904-477-2285
  • Fax:
Mailing address:
  • Phone: 904-477-2285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW3006
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: