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General NPI Number Information
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NPI Number | 1710253943
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Entity Type | Organization
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Legal Business Name | DEVELOPMENT LEARNING CENTER OF ST LUCIE COUNTY FLORIDA INC
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Dates
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Enumeration Date | 04/02/2012
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Last Update Date | 12/12/2012
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Provider Practice Location Address
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Address Line | 2550 SE WALTON RD
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-7168
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Country | US
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Telephone | 772-979-5515
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Fax | 772-335-5855
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Provider Business Mailing Address
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Address Line | 2423 TAMARIND DR
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City | FORT PIERCE
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State | FL
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Zip | 34949-1544
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Country | US
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Telephone | 772-979-5515
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Fax | 772-335-5855
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN EUGENE MAULDIN
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Credential | PHD
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Telephone | 772-871-7800
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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 | PY5121
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License Number State | FL
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