Provider Demographics
NPI:1124788773
Name:DE JESUS, GLORYS (LMHC)
Entity type:Individual
Prefix:
First Name:GLORYS
Middle Name:
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 FLORABLU DR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-3531
Mailing Address - Country:US
Mailing Address - Phone:813-419-3386
Mailing Address - Fax:813-793-4879
Practice Address - Street 1:6338 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3829
Practice Address - Country:US
Practice Address - Phone:813-419-3386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21965101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health