=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336791813
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. LORETTA ANN PLAYER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2019
-----------------------------------------------------
Last Update Date | 11/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 N WOODLAND BLVD
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-866-8976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 1/2 N WOODLAND BLVD
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-4268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-866-8976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | MH19686
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------