1346977311 NPI number — MELBOURNE MEDPSYCH PLLC

Table of content: (NPI 1346977311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346977311 NPI number — MELBOURNE MEDPSYCH PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELBOURNE MEDPSYCH PLLC
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:
1346977311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 AVENUE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32951-2215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-447-0134
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1915 OAK STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-447-0134
Provider Business Practice Location Address Fax Number:
540-932-7611
Provider Enumeration Date:
08/01/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SHOWALTER
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MBR
Authorized Official Telephone Number:
540-447-0134

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PY10639 . This is a "FLORIDA BOARD OF PSYCHOLOGY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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