1194080895 NPI number — DOMINICA J. DEBRAUWERE LCSW, DCSW, INC.

Table of content: (NPI 1194080895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194080895 NPI number — DOMINICA J. DEBRAUWERE LCSW, DCSW, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOMINICA J. DEBRAUWERE LCSW, DCSW, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194080895
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2584 GOVERNORS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIANNA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32446-6399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-443-9801
Provider Business Mailing Address Fax Number:
850-893-6013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4284 KELSON AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIANNA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32446-6399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-443-9801
Provider Business Practice Location Address Fax Number:
850-526-3349
Provider Enumeration Date:
07/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DEBRAUWERE
Authorized Official First Name:
DOMINICA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
THERAPIST/PRESIDENT
Authorized Official Telephone Number:
850-443-9801

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW 3307 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 3307 , 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)

  • Identifier: 1356423537 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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