Healthcare Provider Details

I. General information

NPI: 1356614960
Provider Name (Legal Business Name): BETTY CARVAJAL-PANTALEON MS, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 PLANTATION ISLAND DR S STE 140
ST AUGUSTINE FL
32080-5173
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-392-5434
  • Fax: 904-471-0074
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11064
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: