Basic Information
| Provider Information | |||||||||
| NPI: | 1124118369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURAND | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | FAIRBANKS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4415 SUMMER HAVEN BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322581448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523761611 | ||||||||
| FaxNumber: | 3522714542 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523761611 | ||||||||
| FaxNumber: | 3522714542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 20105 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.