Healthcare Provider Details

I. General information

NPI: 1215132667
Provider Name (Legal Business Name): MARILYN DEPREY LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 A1A S STE 102
ST AUGUSTINE FL
32080-6523
US

IV. Provider business mailing address

3824 HICKORY LN
ST AUGUSTINE FL
32086-7103
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-0208
  • Fax: 904-471-6236
Mailing address:
  • Phone: 904-797-8611
  • Fax: 904-471-6236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH6248
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: