Healthcare Provider Details

I. General information

NPI: 1972564664
Provider Name (Legal Business Name): ELENA C COELLO-JEMMALI PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9729 S DIXIE HWY
PINECREST FL
33156-2806
US

IV. Provider business mailing address

9729 S DIXIE HWY
PINECREST FL
33156-2806
US

V. Phone/Fax

Practice location:
  • Phone: 305-740-3038
  • Fax: 305-740-3038
Mailing address:
  • Phone: 305-740-3038
  • Fax: 305-740-3038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY4371
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: