Provider Demographics
NPI:1003103334
Name:MARK DEARING,LCSW INC
Entity type:Organization
Organization Name:MARK DEARING,LCSW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DEARING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:904-477-5678
Mailing Address - Street 1:1703 MOSSY CYPRESS LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-5023
Mailing Address - Country:US
Mailing Address - Phone:904-477-5678
Mailing Address - Fax:
Practice Address - Street 1:12412 SAN JOSE BLVD STE 401
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8620
Practice Address - Country:US
Practice Address - Phone:904-348-0343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00009531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3224Medicare PIN