=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487046710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAWN HEAD LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2015
-----------------------------------------------------
Last Update Date | 12/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15311 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-787-0154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15408 PRINCEWOOD LN
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34638-6873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-787-0154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW4913
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------