Provider Demographics
NPI:1164416889
Name:WYDEN, RENEE GARCIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:GARCIA
Last Name:WYDEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:DR
Other - First Name:RENEE
Other - Middle Name:GARCIA
Other - Last Name:WYDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD,LCSW
Mailing Address - Street 1:2950 HALCYON LN
Mailing Address - Street 2:SUITE 703
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-6689
Mailing Address - Country:US
Mailing Address - Phone:904-638-7042
Mailing Address - Fax:
Practice Address - Street 1:2950 HALCYON LN
Practice Address - Street 2:SUITE 703
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-6689
Practice Address - Country:US
Practice Address - Phone:904-638-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW6557101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL29717Medicare ID - Type Unspecified