Provider Demographics
NPI:1295392751
Name:DEVEREAUX, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DEVEREAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 BULLDOG BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3188
Mailing Address - Country:US
Mailing Address - Phone:321-727-2990
Mailing Address - Fax:
Practice Address - Street 1:845 CENTURY MEDICAL DR STE B
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2157
Practice Address - Country:US
Practice Address - Phone:321-529-6202
Practice Address - Fax:321-802-6864
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3980171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist