Provider Demographics
NPI:1457826810
Name:THARP-WRIGHT, ANNETTE MARIE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:THARP-WRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11512 LAKE MEAD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9680
Mailing Address - Country:US
Mailing Address - Phone:904-646-0054
Mailing Address - Fax:904-646-0630
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-646-0054
Practice Address - Fax:904-646-0630
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16342101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1174665178Medicaid