Provider Demographics
NPI:1083642300
Name:JUVAN, VIVIAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:
Last Name:JUVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:VIVIAN
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:485 HEFFERON DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6518
Mailing Address - Country:US
Mailing Address - Phone:904-304-5282
Mailing Address - Fax:
Practice Address - Street 1:2120 US 1 S
Practice Address - Street 2:SUITE 104
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4205
Practice Address - Country:US
Practice Address - Phone:904-304-5282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 92671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003022400Medicaid