=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508907098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY DECKER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 10/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8825 PERIMETER PARK BLVD SUITE 601
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-997-0195
-----------------------------------------------------
Fax | 904-997-0163
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8825 PERIMETER PARK BLVD SUITE 601
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-997-0195
-----------------------------------------------------
Fax | 904-997-0163
-----------------------------------------------------
=====================================================
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 | SW6405
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------