1659666543 NPI number — JAMES BERWICK, LCSW

Table of content: (NPI 1659666543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659666543 NPI number — JAMES BERWICK, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES BERWICK, LCSW
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:
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:
1659666543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 22ND ST
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:
32084-1798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-599-3602
Provider Business Mailing Address Fax Number:
904-461-8368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 22ND ST
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:
32084-1798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-599-3602
Provider Business Practice Location Address Fax Number:
904-461-8368
Provider Enumeration Date:
06/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BERWICK
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
904-599-3602

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW1692 , 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: 761949900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: Z4535 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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