Provider Demographics
NPI:1528437753
Name:ALTIDOR, ADELLE
Entity type:Individual
Prefix:
First Name:ADELLE
Middle Name:
Last Name:ALTIDOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ADELLE
Other - Middle Name:ALTIDOR
Other - Last Name:DORSAINRRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHC
Mailing Address - Street 1:525 NW LAKE WHITNEY PL
Mailing Address - Street 2:SUITES # 102/103
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 NW LAKE WHITNEY PL
Practice Address - Street 2:SUITES #102/103
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1605
Practice Address - Country:US
Practice Address - Phone:772-337-8164
Practice Address - Fax:772-337-8165
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA433-000-81-722-1OtherDRIVERS LICENSE