MEDICARE: MILESTONES CHILD PSYCHOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1053296459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILESTONES CHILD PSYCHOLOGY

Provider Business Mailing Address
First Line	:	3204 SAWGRASS VILLAGE CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-5039
Country	:	US
Telephone Number	:	904-615-7504
Fax Number	:

Provider Business Practice Location Address
First Line	:	3204 SAWGRASS VILLAGE CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-5039
Country	:	US
Telephone Number	:	904-615-7504
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. LEE ANN ANNOTTI
Credential	:	PHD
Telephone Number	:	904-615-7504

Provider Enumeration Date	:	08/06/2025
Last Update Date	:	08/06/2025

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