Provider Demographics
NPI:1588243273
Name:QUEALLY, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:QUEALLY
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 1:726 GRAPE IVY LN
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-2066
Mailing Address - Country:US
Mailing Address - Phone:386-847-1089
Mailing Address - Fax:
Practice Address - Street 1:140 S BEACH ST STE 310
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4409
Practice Address - Country:US
Practice Address - Phone:386-847-1089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health