Healthcare Provider Details

I. General information

NPI: 1104788827
Provider Name (Legal Business Name): RICHARD JERRID DEWALDEN LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 BOXELDER AVE
MINNEOLA FL
34715-6095
US

IV. Provider business mailing address

881 BOXELDER AVE
MINNEOLA FL
34715-6095
US

V. Phone/Fax

Practice location:
  • Phone: 407-761-3953
  • Fax:
Mailing address:
  • Phone: 407-761-3953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: