Provider Demographics
NPI:1083236343
Name:DEZELIC, MARIE (PHD, LMHC)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:
Last Name:DEZELIC
Suffix:
Gender:F
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 S LE JEUNE RD STE 537
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-5832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2655 S LE JEUNE RD STE 537
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5832
Practice Address - Country:US
Practice Address - Phone:305-775-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
FLMH13681101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling