Provider Demographics
NPI:1013404946
Name:DELUCIA, KATHLEEN MARY (CAP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:DELUCIA
Suffix:
Gender:F
Credentials:CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3574 US HIGHWAY 1 S STE 101-104
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6466
Mailing Address - Country:US
Mailing Address - Phone:904-217-7161
Mailing Address - Fax:904-217-4075
Practice Address - Street 1:3574 US HIGHWAY 1 S STE 101-104
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6466
Practice Address - Country:US
Practice Address - Phone:904-217-7161
Practice Address - Fax:904-217-4075
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5478101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)