Healthcare Provider Details

I. General information

NPI: 1285253005
Provider Name (Legal Business Name): MICHAEL SHANE BERMES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SCOTT LN
JONESBOROUGH TN
37659-1526
US

IV. Provider business mailing address

120 SCOTT LN
JONESBOROUGH TN
37659-1526
US

V. Phone/Fax

Practice location:
  • Phone: 727-518-5890
  • Fax:
Mailing address:
  • Phone: 727-518-5890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12174
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904009600
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: