Healthcare Provider Details

I. General information

NPI: 1891201638
Provider Name (Legal Business Name): VIVIAN ANA LORETDEMOLA PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VIVIAN ANA ROY PH.D.

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3599 W. LAKE MARY BLVD, SUITE B2
LAKE MARY FL
32746
US

IV. Provider business mailing address

1502 N. PENINSULA DRIVE
DAYTONA BEACH FL
32118
US

V. Phone/Fax

Practice location:
  • Phone: 386-675-7467
  • Fax: 386-256-3665
Mailing address:
  • Phone: 386-675-7467
  • Fax: 386-256-3665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY5437
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY5437
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: