Basic Information
| Provider Information | |||||||||
| NPI: | 1346512522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAUNTLETT | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | WINTHROP | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJP - PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443199 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 6266 DUPONT STATION CT E | ||||||||
| Address2: | UFJAX - DEPT. OF PSYCHIATRY | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831038 | ||||||||
| FaxNumber: | 9043831660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2012 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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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 | 101YM0800X | MH11076 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 004534600 | 05 | FL | MEDICAID |