Provider Demographics
NPI:1306081179
Name:DEFOREST, PAULA (PHD)
Entity type:Individual
Prefix:DR
First Name:PAULA
Middle Name:
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 ROCKLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5404
Mailing Address - Country:US
Mailing Address - Phone:321-305-5068
Mailing Address - Fax:
Practice Address - Street 1:2020 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-2335
Practice Address - Country:US
Practice Address - Phone:321-952-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004766103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent