Provider Demographics
NPI:1548967094
Name:DILORETO, ROSS
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:DILORETO
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:PO BOX 2227
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-2227
Mailing Address - Country:US
Mailing Address - Phone:904-655-8710
Mailing Address - Fax:
Practice Address - Street 1:4375 US HIGHWAY 17 STE 103
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4832
Practice Address - Country:US
Practice Address - Phone:904-269-0886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21867101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health