MEDICARE: CHASSIDY HARVEY 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	1041C0700X	Clinical Social Worker	SW 12341	FL

General Provider Information

NPI Number	:	1134574577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHASSIDY HARVEY LCSW

Provider Business Mailing Address
First Line	:	731 DUVAL STATION RD
Second Line	:	STE. 107-204
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-0800
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	731 DUVAL STATION RD
Second Line	:	STE. 107-204
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-0800
Country	:	US
Telephone Number	:	904-655-1806
Fax Number	:

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

Provider Enumeration Date	:	05/03/2016
Last Update Date	:	05/03/2016

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