Provider Demographics
NPI:1114191426
Name:MALL, JULIE ANNA (PSY21501D)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANNA
Last Name:MALL
Suffix:
Gender:F
Credentials:PSY21501D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 TORTOISE VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:432 TORTOISE VIEW CIRCLE
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-3801
Practice Address - Country:US
Practice Address - Phone:321-432-2865
Practice Address - Fax:321-777-5806
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6653103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical