Provider Demographics
NPI:1922348416
Name:PONTE VEDRA PSYCHOLOGISTS, LLC
Entity Type:Organization
Organization Name:PONTE VEDRA PSYCHOLOGISTS, LLC
Other - Org Name:PONTE VEDRA PSYCHOLOGISTS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARAMONI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-285-4229
Mailing Address - Street 1:2304 SAWGRASS VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-5007
Mailing Address - Country:US
Mailing Address - Phone:904-285-4229
Mailing Address - Fax:904-280-9585
Practice Address - Street 1:2304 SAWGRASS VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5007
Practice Address - Country:US
Practice Address - Phone:904-285-4229
Practice Address - Fax:904-280-9585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73863Medicare UPIN