Healthcare Provider Details

I. General information

NPI: 1548967094
Provider Name (Legal Business Name): ROSS DILORETO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2023
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4375 US HIGHWAY 17 STE 103
FLEMING ISLAND FL
32003-4832
US

IV. Provider business mailing address

PO BOX 2227
ORANGE PARK FL
32067-2227
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-0886
  • Fax:
Mailing address:
  • Phone: 904-655-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21867
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: