Healthcare Provider Details

I. General information

NPI: 1720199300
Provider Name (Legal Business Name): PEARLENE S. GARDBERG-DELUCA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

378 CENTER POINTE CIRCLE SUITE 1280
ALTAMONTE SPRINGS FL
32701-3442
US

IV. Provider business mailing address

378 CENTER POINTE CIRCLE SUITE 1280
ALTAMONTE SPRINGS FL
32701-3442
US

V. Phone/Fax

Practice location:
  • Phone: 407-862-5959
  • Fax: 407-774-5573
Mailing address:
  • Phone: 407-862-5959
  • Fax: 407-774-5573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY0004744
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: