MEDICARE: CRISTINA CHINCHILLA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1073051082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRISTINA CHINCHILLA LCSW

Provider Business Mailing Address
First Line	:	7643 GATE PKWY # 104-1034
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-3092
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7643 GATE PKWY # 104-1034
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-3092
Country	:	US
Telephone Number	:	904-649-2665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2017
Last Update Date	:	09/24/2021

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