Provider Demographics
NPI:1720199300
Name:GARDBERG-DELUCA, PEARLENE S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PEARLENE
Middle Name:S
Last Name:GARDBERG-DELUCA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 CENTER POINTE CIRCLE
Mailing Address - Street 2:SUITE 1280
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-3442
Mailing Address - Country:US
Mailing Address - Phone:407-862-5959
Mailing Address - Fax:407-774-5573
Practice Address - Street 1:378 CENTER POINTE CIRCLE
Practice Address - Street 2:SUITE 1280
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-3442
Practice Address - Country:US
Practice Address - Phone:407-862-5959
Practice Address - Fax:407-774-5573
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004744103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
59356Medicare ID - Type Unspecified
R03810Medicare UPIN