Provider Demographics
NPI:1063496453
Name:MEEHAN, MICHAEL JOHN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:MEEHAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SAINT JOHNS MEDICAL PK DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5343
Mailing Address - Country:US
Mailing Address - Phone:904-797-2705
Mailing Address - Fax:904-797-2820
Practice Address - Street 1:9 SAINT JOHNS MEDICAL PK DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5343
Practice Address - Country:US
Practice Address - Phone:904-797-2705
Practice Address - Fax:904-797-2820
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW10471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1577OtherBLUE CROSS BLUE SHIELD
FLZ1577OtherBLUE CROSS BLUE SHIELD