Provider Demographics
NPI:1427247303
Name:FEAZELL, DAVID MICHAEL (PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:FEAZELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CATHEDRAL PL
Mailing Address - Street 2:SUITE 412
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-4473
Mailing Address - Country:US
Mailing Address - Phone:904-824-9975
Mailing Address - Fax:904-824-9943
Practice Address - Street 1:24 CATHEDRAL PL
Practice Address - Street 2:SUITE 412
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4473
Practice Address - Country:US
Practice Address - Phone:904-824-9975
Practice Address - Fax:904-824-9943
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2187103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical