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General NPI Number Information
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NPI Number | 1053711630
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Entity Type | Individual
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Provider Name | MRS. KIMBERLY MCGOWAN
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Gender | Female
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Dates
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Enumeration Date | 09/02/2014
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Last Update Date | 12/06/2017
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Provider Practice Location Address
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Address Line | 460 TOWN PLAZA AVE STE 260
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City | PONTE VEDRA
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State | FL
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Zip | 32081-5139
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Country | US
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Telephone | 904-599-1243
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Fax |
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Provider Business Mailing Address
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Address Line | 266 BERMUDA GREENS AVE
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City | PONTE VEDRA
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State | FL
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Zip | 32081-4390
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Country | US
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Telephone | 954-536-1121
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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