Provider Demographics
NPI:1679939219
Name:MERVENNE, THERESA (LCSW, MSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MERVENNE
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 34TH AVE N
Mailing Address - Street 2:#7844
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33734-8064
Mailing Address - Country:US
Mailing Address - Phone:206-200-6059
Mailing Address - Fax:
Practice Address - Street 1:735 ARLINGTON AVE N
Practice Address - Street 2:SUITE 212
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3652
Practice Address - Country:US
Practice Address - Phone:206-200-6059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW120661041C0700X
WALW601731151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical