1003228032 NPI number — DEBORAH M. THEVENIN, PH.D., LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003228032 NPI number — DEBORAH M. THEVENIN, PH.D., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEBORAH M. THEVENIN, PH.D., LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003228032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 BAY RD
Provider Second Line Business Mailing Address:
UNIT 716 SOUTH
Provider Business Mailing Address City Name:
MIAMI BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33139-3252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-495-7603
Provider Business Mailing Address Fax Number:
305-666-4311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7685 SW 104TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33156-3161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-666-8000
Provider Business Practice Location Address Fax Number:
305-666-4311
Provider Enumeration Date:
05/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
THEVENIN
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
MORRISON
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
305-495-7603

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY4442 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1376846295 . This is a "NPI TYPE 1" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: FLPY4442 . This is a "FLORIDA STATE PSYCHOLOGIST LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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