=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619673340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KORTNEY CLINTON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2023
-----------------------------------------------------
Last Update Date | 03/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 LLOYD SUBDIVISION RD
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32344-8802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-296-2493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 332
-----------------------------------------------------
City | LLOYD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32337-0332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-296-2493
-----------------------------------------------------
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 | SW21011
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------