Provider Demographics
NPI:1376071910
Name:VALLETTA, JONATHAN (MA, RMHCI)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:VALLETTA
Suffix:
Gender:M
Credentials:MA, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:983 VILLA DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:880 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2909
Practice Address - Country:US
Practice Address - Phone:321-914-0612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health