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General NPI Number Information
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NPI Number | 1891201638
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Entity Type | Individual
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Provider Name | VIVIAN ANA LORETDEMOLA PH.D
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Gender | Female
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Dates
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Enumeration Date | 12/15/2017
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Last Update Date | 12/15/2017
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Provider Practice Location Address
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Address Line | 3599 W. LAKE MARY BLVD, SUITE B2
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City | LAKE MARY
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State | FL
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Zip | 32746
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Country | US
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Telephone | 386-675-7467
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Fax | 386-256-3665
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Provider Business Mailing Address
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Address Line | 1502 N. PENINSULA DRIVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32118
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Country | US
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Telephone | 386-675-7467
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Fax | 386-256-3665
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY5437
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY5437
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License Number State | FL
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