Provider Demographics
NPI:1851776348
Name:PAULA DEFOREST PHD LLC
Entity Type:Organization
Organization Name:PAULA DEFOREST PHD LLC
Other - Org Name:PAULA DEFOREST PHD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFOREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-305-5068
Mailing Address - Street 1:2290 ROCKLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5404
Mailing Address - Country:US
Mailing Address - Phone:321-305-5068
Mailing Address - Fax:
Practice Address - Street 1:1425 AURORA RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5315
Practice Address - Country:US
Practice Address - Phone:321-242-3110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004766103T00000X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X, 103TM1800X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty