Provider Demographics
NPI:1326658824
Name:CARR-DE VRIES, MARY ELIZABETH (IMH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:CARR-DE VRIES
Suffix:
Gender:F
Credentials:IMH
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RMHCI
Mailing Address - Street 1:5095 S WASHINGTON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7333
Mailing Address - Country:US
Mailing Address - Phone:407-917-6828
Mailing Address - Fax:
Practice Address - Street 1:5095 S WASHINGTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7333
Practice Address - Country:US
Practice Address - Phone:407-917-6828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19729101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health