MEDICARE: MRS. PAMELA E DERR LMHC

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	101YM0800X	Mental Health Counselor	MH4576	FL

General Provider Information

NPI Number	:	1740297563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAMELA E DERR LMHC

Provider Business Mailing Address
First Line	:	89 JOHNSON BEACH WAY
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-2766
Country	:	US
Telephone Number	:	386-503-9674
Fax Number	:	386-439-6605

Provider Business Practice Location Address
First Line	:	210 MOODY BLVD
Second Line	:
City	:	FLAGLER BEACH
State	:	FL
Zip	:	32136-3372
Country	:	US
Telephone Number	:	386-503-9674
Fax Number	:	386-439-6605

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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