Provider Demographics
NPI:1013116136
Name:VAIL, JOAN A (PSYD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:A
Last Name:VAIL
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 1:153 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-5572
Mailing Address - Country:US
Mailing Address - Phone:941-497-5522
Mailing Address - Fax:941-497-5556
Practice Address - Street 1:153 CENTER RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5572
Practice Address - Country:US
Practice Address - Phone:941-497-5522
Practice Address - Fax:941-497-5556
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6759103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74034Medicare PIN