Healthcare Provider Details

I. General information

NPI: 1306081179
Provider Name (Legal Business Name): PAULA DEFOREST PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 COMMERCE DR
WEST MELBOURNE FL
32904-2335
US

IV. Provider business mailing address

2290 ROCKLEDGE DR
ROCKLEDGE FL
32955-5404
US

V. Phone/Fax

Practice location:
  • Phone: 321-952-6000
  • Fax:
Mailing address:
  • Phone: 321-305-5068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY0004766
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: