MEDICARE: EMERALD COAST PSYCHIATRIC CARE PA

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	2084P0800X	Psychiatry Physician	53869	FL

General Provider Information

NPI Number	:	1679613962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD COAST PSYCHIATRIC CARE PA

Provider Business Mailing Address
First Line	:	124 E MIRACLE STRIP PKWY
Second Line	:	SUITE 602
City	:	MARY ESTHER
State	:	FL
Zip	:	32569-1988
Country	:	US
Telephone Number	:	850-244-0101
Fax Number	:

Provider Business Practice Location Address
First Line	:	124 E MIRACLE STRIP PKWY
Second Line	:	SUITE 602
City	:	MARY ESTHER
State	:	FL
Zip	:	32569-1988
Country	:	US
Telephone Number	:	850-244-0101
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VICTOR F DEMOYA
Credential	:	M.D.
Telephone Number	:	850-244-0101

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	08/22/2020

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Practice Location Address:

124 E MIRACLE STRIP PKWY , SUITE 302
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1700937638 — DR. JAMES L TUCKER PH.D.
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1467839894 — MRS. CARRIE PILENZA RBT
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1578000683 — JOANNA R. DAVIS, LMHC CAP
Practice Location Address:

124 E MIRACLE STRIP PKWY , SUITE 602
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Practice Location Address:

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1740750652 — MRS. SAARAH C WILLMAN
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