Provider Demographics
NPI:1972153633
Name:KEFALIANOS, VERONICA
Entity Type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:
Last Name:KEFALIANOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 FORT FLORIDA RD
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-9714
Mailing Address - Country:US
Mailing Address - Phone:386-801-7774
Mailing Address - Fax:
Practice Address - Street 1:454 FORT FLORIDA RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-9714
Practice Address - Country:US
Practice Address - Phone:386-801-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106SOOOOOX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024074300Medicaid