Provider Demographics
NPI:1457404980
Name:DELOACHE, MARY ELLEN (MED)
Entity type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:DELOACHE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 ALISA CIR NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-4371
Mailing Address - Country:US
Mailing Address - Phone:727-526-5519
Mailing Address - Fax:727-526-5519
Practice Address - Street 1:801 6TH ST S
Practice Address - Street 2:DEPT 7470
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4816
Practice Address - Country:US
Practice Address - Phone:727-767-6726
Practice Address - Fax:727-767-4715
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist