Healthcare Provider Details

I. General information

NPI: 1316490147
Provider Name (Legal Business Name): MS. LORETTA MICHELE DELOACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 27TH ST. S. STE. 3
BRADENTON FL
34208
US

IV. Provider business mailing address

510 OAKHURST ST
BRANDON FL
33511-7228
US

V. Phone/Fax

Practice location:
  • Phone: 941-748-2697
  • Fax:
Mailing address:
  • Phone: 813-719-0473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: