Healthcare Provider Details

I. General information

NPI: 1851776348
Provider Name (Legal Business Name): PAULA DEFOREST PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 AURORA RD
MELBOURNE FL
32935-5315
US

IV. Provider business mailing address

2290 ROCKLEDGE DR
ROCKLEDGE FL
32955-5404
US

V. Phone/Fax

Practice location:
  • Phone: 321-242-3110
  • Fax:
Mailing address:
  • Phone: 321-305-5068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY0004766
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY0004766
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0004766
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY0004766
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPY0004766
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPY0004766
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPY0004766
License Number StateFL
# 8
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY0004766
License Number StateFL

VIII. Authorized Official

Name: DR. PAULA DEFOREST
Title or Position: PSYCHOLOGIST
Credential:
Phone: 321-305-5068