Healthcare Provider Details

I. General information

NPI: 1033364971
Provider Name (Legal Business Name): MARY ALSTON KERLLENEVICH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S PONCE DE LEON BLVD STE 1
ST AUGUSTINE FL
32084-6013
US

IV. Provider business mailing address

4900 US HIGHWAY 1 N SUITE 400
ST AUGUSTINE FL
32095-6271
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7733
  • Fax: 904-829-9768
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY 7744
License Number StateFL

VIII. Authorized Official

Name: MARY A KERLLENEVICH
Title or Position: MGRM
Credential: PH.D.
Phone: 904-824-7733