Basic Information
| Provider Information | |||||||||
| NPI: | 1457404980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELOACHE | ||||||||
| FirstName: | MARY ELLEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.ED. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4623 ALISA CIR NE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337034371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275265519 | ||||||||
| FaxNumber: | 7275265519 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 6TH ST S | ||||||||
| Address2: | DEPT 7470 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277676726 | ||||||||
| FaxNumber: | 7277674715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | X | Behavioral Health & Social Service Providers | Social Worker | 222Q00000X | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.