Provider Demographics
NPI:1912204470
Name:DELLER, CLETUS LEON (LMHC INTERN)
Entity Type:Individual
Prefix:MR
First Name:CLETUS
Middle Name:LEON
Last Name:DELLER
Suffix:
Gender:M
Credentials:LMHC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96173 PINEY ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-0858
Mailing Address - Country:US
Mailing Address - Phone:772-321-3306
Mailing Address - Fax:
Practice Address - Street 1:96173 PINEY ISLAND DR
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-0858
Practice Address - Country:US
Practice Address - Phone:772-321-3306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10772101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH10772OtherMENTAL HEALTH LICENSE