Provider Demographics
NPI:1891201638
Name:LORETDEMOLA, VIVIAN ANA (PHD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:ANA
Last Name:LORETDEMOLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:VIVIAN
Other - Middle Name:ANA
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1502 N. PENINSULA DRIVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118
Mailing Address - Country:US
Mailing Address - Phone:386-675-7467
Mailing Address - Fax:386-256-3665
Practice Address - Street 1:3599 W. LAKE MARY BLVD, SUITE B2
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:386-675-7467
Practice Address - Fax:386-256-3665
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5437103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical