Healthcare Provider Details

I. General information

NPI: 1821664368
Provider Name (Legal Business Name): DR. GLADYS VANESSA MATTA DEMOCKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 UNIVERSITY PKWY STE 219
SARASOTA FL
34243-2809
US

IV. Provider business mailing address

6025 FERNDELL ST
BRADENTON FL
34203-7325
US

V. Phone/Fax

Practice location:
  • Phone: 800-687-1938
  • Fax:
Mailing address:
  • Phone: 941-224-7213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY7298
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: