Provider Demographics
NPI:1033364971
Name:MARY ALSTON KERLLENEVICH, LLC
Entity Type:Organization
Organization Name:MARY ALSTON KERLLENEVICH, LLC
Other - Org Name:MARY ALSTON KERLLENEVICH, PH.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KERLLENEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-824-7733
Mailing Address - Street 1:4900 US HIGHWAY 1 N
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-6271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 S PONCE DE LEON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6013
Practice Address - Country:US
Practice Address - Phone:904-824-7733
Practice Address - Fax:904-829-9768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7744103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty