Healthcare Provider Details

I. General information

NPI: 1457404980
Provider Name (Legal Business Name): MARY ELLEN DELOACHE M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 6TH ST S DEPT 7470
ST PETERSBURG FL
33701-4816
US

IV. Provider business mailing address

4623 ALISA CIR NE
ST PETERSBURG FL
33703-4371
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-6726
  • Fax: 727-767-4715
Mailing address:
  • Phone: 727-526-5519
  • Fax: 727-526-5519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: