Provider Demographics
NPI:1184875312
Name:VERMILLERA, CHRISTA (PHD)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:
Last Name:VERMILLERA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 DIXON BLVD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-6806
Mailing Address - Country:US
Mailing Address - Phone:321-446-2113
Mailing Address - Fax:321-241-4605
Practice Address - Street 1:937 DIXON BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-6806
Practice Address - Country:US
Practice Address - Phone:321-446-2113
Practice Address - Fax:321-241-4605
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9873101YM0800X
FL1-21-47877103K00000X
FLMH 9873101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1-21-47877Other103K00000X
FL772265Medicaid