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General NPI Number Information
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NPI Number | 1386713048
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Entity Type | Individual
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Provider Name | MARY ALSTON KERLLENEVICH PH.D.
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Gender | Female
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 08/12/2008
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Provider Practice Location Address
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Address Line | 1100 S PONCE DE LEON BLVD STE 1
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-6013
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Country | US
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Telephone | 904-824-7733
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Fax | 904-829-9768
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Provider Business Mailing Address
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Address Line | 1100 S PONCE DE LEON BLVD STE 1
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-6013
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Country | US
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Telephone | 904-824-7733
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Fax | 904-829-9768
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY7744
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY7744
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License Number State | FL
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