Provider Demographics
NPI:1386713048
Name:KERLLENEVICH, MARY ALSTON (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALSTON
Last Name:KERLLENEVICH
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 1:1100 S PONCE DE LEON BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6013
Mailing Address - Country:US
Mailing Address - Phone:904-824-7733
Mailing Address - Fax:904-829-9768
Practice Address - Street 1:1100 S PONCE DE LEON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6013
Practice Address - Country:US
Practice Address - Phone:904-824-7733
Practice Address - Fax:904-829-9768
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7744103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical