1386322980 NPI number — MRS. JULIE MARIE VANDEUSEN LCSW

Table of content: MRS. JULIE MARIE VANDEUSEN LCSW (NPI 1386322980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386322980 NPI number — MRS. JULIE MARIE VANDEUSEN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDEUSEN
Provider First Name:
JULIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOOD
Provider Other First Name:
JULIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386322980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1941 LYNDHURST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32092-1092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1941 LYNDHURST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32092-1092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-403-5245
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW21490 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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