Provider Demographics
NPI:1457516767
Name:FORTENBERRY, DELILAH D
Entity Type:Individual
Prefix:
First Name:DELILAH
Middle Name:D
Last Name:FORTENBERRY
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 1:25703 ALDUS DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-5653
Mailing Address - Country:US
Mailing Address - Phone:813-482-1187
Mailing Address - Fax:813-358-3201
Practice Address - Street 1:1001 E BAKER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3700
Practice Address - Country:US
Practice Address - Phone:813-754-5555
Practice Address - Fax:813-754-5552
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9252101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health