Healthcare Provider Details

I. General information

NPI: 1972153633
Provider Name (Legal Business Name): MRS. VERONICA KEFALIANOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 FORT FLORIDA RD
DEBARY FL
32713-9714
US

IV. Provider business mailing address

454 FORT FLORIDA RD
DEBARY FL
32713-9714
US

V. Phone/Fax

Practice location:
  • Phone: 386-801-7774
  • Fax:
Mailing address:
  • Phone: 386-801-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106SOOOOOX
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: