Provider Demographics
NPI:1578715967
Name:DERIVAL, ANNE DYNA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANNE
Middle Name:DYNA
Last Name:DERIVAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1135
Mailing Address - Country:US
Mailing Address - Phone:904-396-8734
Mailing Address - Fax:904-396-8759
Practice Address - Street 1:4161 CARMICHAEL AVE
Practice Address - Street 2:BLDG 3300, SUITE 150
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2353
Practice Address - Country:US
Practice Address - Phone:904-396-8734
Practice Address - Fax:904-396-8759
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical