=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619264710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALERIE DEVILLE, LMHC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2011
-----------------------------------------------------
Last Update Date | 07/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2706 OLD MOULTRIE RD
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-5447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-540-2840
-----------------------------------------------------
Fax | 904-461-8368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 COLON AVE
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-1271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-540-2840
-----------------------------------------------------
Fax | 904-461-8368
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | VALERIE DEVILLE
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 904-540-2840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH8104
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------