Provider Demographics
NPI:1306411368
Name:MEMOLI, PETER JOSEPH
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOSEPH
Last Name:MEMOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 3RD AVE N UNIT 3513
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-7646
Mailing Address - Country:US
Mailing Address - Phone:941-704-5502
Mailing Address - Fax:
Practice Address - Street 1:3151 3RD AVE N UNIT 3513
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-7646
Practice Address - Country:US
Practice Address - Phone:941-704-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL605828106S00000X
FLBACB605283106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty