Healthcare Provider Details

I. General information

NPI: 1114874088
Provider Name (Legal Business Name): PAMELA DENISE MARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 PASEO REYES DR
ST AUGUSTINE FL
32095-8464
US

IV. Provider business mailing address

705 S BEACH ST APT 48
DAYTONA BEACH FL
32114-5415
US

V. Phone/Fax

Practice location:
  • Phone: 386-287-0519
  • Fax:
Mailing address:
  • Phone: 386-333-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH28909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: