Basic Information
| Provider Information | |||||||||
| NPI: | 1619341906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AUGUSTIN | ||||||||
| FirstName: | RAYNOLD | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 W LAKEVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325011857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504693500 | ||||||||
| FaxNumber: | 8505951400 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 W LAKEVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325011857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504693500 | ||||||||
| FaxNumber: | 8505951400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2015 | ||||||||
| LastUpdateDate: | 02/29/2016 | ||||||||
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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 | SW13318 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 016275000 | 05 | FL | MEDICAID |