Provider Demographics
NPI:1285885061
Name:MALLOZZI, JON MICHAEL
Entity type:Individual
Prefix:
First Name:JON
Middle Name:MICHAEL
Last Name:MALLOZZI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 DELTONA BLVD
Mailing Address - Street 2:SUITE K
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-7162
Mailing Address - Country:US
Mailing Address - Phone:386-860-1776
Mailing Address - Fax:
Practice Address - Street 1:840 DELTONA BLVD
Practice Address - Street 2:SUITE K
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-7162
Practice Address - Country:US
Practice Address - Phone:386-860-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT1178106H00000X
FLMH10617101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist