Healthcare Provider Details

I. General information

NPI: 1619264710
Provider Name (Legal Business Name): VALERIE DEVILLE, LMHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2011
Last Update Date: 07/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2706 OLD MOULTRIE RD
ST AUGUSTINE FL
32086-5447
US

IV. Provider business mailing address

112 COLON AVE
ST AUGUSTINE FL
32084-1271
US

V. Phone/Fax

Practice location:
  • Phone: 904-540-2840
  • Fax: 904-461-8368
Mailing address:
  • Phone: 904-540-2840
  • Fax: 904-461-8368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8104
License Number StateFL

VIII. Authorized Official

Name: VALERIE DEVILLE
Title or Position: OWNER/OPERATOR
Credential: LMHC
Phone: 904-540-2840