Provider Demographics
NPI:1720504517
Name:BRUMMER, DIANA BAKER (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:BAKER
Last Name:BRUMMER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 600903
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32260-0903
Mailing Address - Country:US
Mailing Address - Phone:904-419-7435
Mailing Address - Fax:
Practice Address - Street 1:157 HAMPTON POINT DR STE 1
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3054
Practice Address - Country:US
Practice Address - Phone:904-419-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW164911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical