1336490093 NPI number — FLORIDA NEUROPSYCHOLOGY

Table of content: (NPI 1336490093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336490093 NPI number — FLORIDA NEUROPSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA NEUROPSYCHOLOGY
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:
1336490093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3951 SERENADE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33811-8603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 S ALEXANDER ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
PLANT CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33563-8408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-204-8318
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CARREO
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
NEUROPSYCHOLOGIST
Authorized Official Telephone Number:
727-204-8318

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  PY8596 , 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)