Healthcare Provider Details

I. General information

NPI: 1467606616
Provider Name (Legal Business Name): DR. LAWRENCE JOHN DE LAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 ORIGINS MAIN ST STE 219
INLET BEACH FL
32461-8647
US

IV. Provider business mailing address

26 ORIGINS MAIN ST STE 219
INLET BEACH FL
32461-8647
US

V. Phone/Fax

Practice location:
  • Phone: 850-407-2095
  • Fax: 850-407-2095
Mailing address:
  • Phone: 850-407-2095
  • Fax: 850-407-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD28817
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301505912
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number57260-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD61573411
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME155724
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: