MEDICARE: DIANA BAKER BRUMMER MSW, 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	SW16491	FL

General Provider Information

NPI Number	:	1720504517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA BAKER BRUMMER MSW, LCSW

Provider Business Mailing Address
First Line	:	PO BOX 600903
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32260-0903
Country	:	US
Telephone Number	:	904-419-7435
Fax Number	:

Provider Business Practice Location Address
First Line	:	157 HAMPTON POINT DR STE 1
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32092-3054
Country	:	US
Telephone Number	:	904-419-7435
Fax Number	:

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

Provider Enumeration Date	:	08/14/2017
Last Update Date	:	07/22/2019

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