Healthcare Provider Details

I. General information

NPI: 1790143964
Provider Name (Legal Business Name): MARYBETH RESKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13998 SE 121ST PL
OCKLAWAHA FL
32179-5378
US

IV. Provider business mailing address

13998 SE 121ST PL
OCKLAWAHA FL
32179-5378
US

V. Phone/Fax

Practice location:
  • Phone: 352-804-2075
  • Fax:
Mailing address:
  • Phone: 352-804-2075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: