Healthcare Provider Details

I. General information

NPI: 1245952621
Provider Name (Legal Business Name): KEISHA DIOMARIS GONZALEZ PELLOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5449 S SEMORAN BLVD
ORLANDO FL
32822-1722
US

IV. Provider business mailing address

5449 S SEMORAN BLVD
ORLANDO FL
32822-1722
US

V. Phone/Fax

Practice location:
  • Phone: 904-947-0376
  • Fax:
Mailing address:
  • Phone: 904-947-0376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number7005
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: