=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003103334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK DEARING,LCSW INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2011
-----------------------------------------------------
Last Update Date | 02/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12412 SAN JOSE BLVD STE 401
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-8620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-348-0343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1703 MOSSY CYPRESS LN
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-477-5678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MARK RICHARD DEARING
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 904-477-5678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW0000953
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------