Provider Demographics
NPI:1063647618
Name:GROVE, LETICIA FREELAND (MA, LMHC)
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:FREELAND
Last Name:GROVE
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19974 FRONT BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-4431
Mailing Address - Country:US
Mailing Address - Phone:850-291-1344
Mailing Address - Fax:850-250-5759
Practice Address - Street 1:16500 PANAMA CITY BEACH PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-2251
Practice Address - Country:US
Practice Address - Phone:850-291-1344
Practice Address - Fax:850-250-5759
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9752101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health