Provider Demographics
NPI:1891928420
Name:DESMARAIS, NATHALY SHOUA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NATHALY
Middle Name:SHOUA
Last Name:DESMARAIS
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 1:3000 SW 121ST AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-1318
Mailing Address - Country:US
Mailing Address - Phone:954-600-9190
Mailing Address - Fax:954-473-4267
Practice Address - Street 1:5400 S UNIVERSITY DR
Practice Address - Street 2:SUITE 119
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5312
Practice Address - Country:US
Practice Address - Phone:954-600-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7955103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist