Provider Demographics
NPI:1356749303
Name:EXAVIER, FREEDAH DESTINY (MS)
Entity type:Individual
Prefix:
First Name:FREEDAH
Middle Name:DESTINY
Last Name:EXAVIER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 SW BYRON ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1922
Mailing Address - Country:US
Mailing Address - Phone:561-906-4743
Mailing Address - Fax:
Practice Address - Street 1:1601 NE BRAILLE PL
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-5345
Practice Address - Country:US
Practice Address - Phone:561-906-4743
Practice Address - Fax:772-444-3735
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FL19949101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251B00000XAgenciesCase Management