Healthcare Provider Details

I. General information

NPI: 1821823873
Provider Name (Legal Business Name): DAIZJA V BRAZILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S HWY 27 STE B201
CLERMONT FL
34711-6816
US

IV. Provider business mailing address

556 LITTLE RIVER LOOP APT 238
ALTAMONTE SPG FL
32714-1781
US

V. Phone/Fax

Practice location:
  • Phone: 352-606-0000
  • Fax:
Mailing address:
  • Phone: 850-346-1749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: