Provider Demographics
NPI:1124016621
Name:DESANTO, GERARDA (PSYD)
Entity Type:Individual
Prefix:
First Name:GERARDA
Middle Name:
Last Name:DESANTO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8205 NW 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-5093
Mailing Address - Country:US
Mailing Address - Phone:954-720-4416
Mailing Address - Fax:
Practice Address - Street 1:8205 NW 71ST AVE
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-5093
Practice Address - Country:US
Practice Address - Phone:954-720-4416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5078103T00000X, 103TC0700X, 103TC1900X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59644ZMedicare ID - Type Unspecified