Provider Demographics
NPI:1326301706
Name:DEVEREUX
Entity Type:Organization
Organization Name:DEVEREUX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-281-3840
Mailing Address - Street 1:1010 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5850 T G LEE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-4407
Practice Address - Country:US
Practice Address - Phone:321-281-3840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL160994624261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029573621Medicaid