1609147479 NPI number — MICHAEL H. RATHJENS, PSY.D, PA

Table of content: MARK CONG XU MD (NPI 1063048569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609147479 NPI number — MICHAEL H. RATHJENS, PSY.D, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL H. RATHJENS, PSY.D, PA
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:
1609147479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4682 FOXVIEW PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE WORTH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33467-3510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-790-7975
Provider Business Mailing Address Fax Number:
561-790-4788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12012 S SHORE BLVD
Provider Second Line Business Practice Location Address:
STE 108
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33414-6203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-790-7975
Provider Business Practice Location Address Fax Number:
561-790-4788
Provider Enumeration Date:
01/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RATHJENS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-790-7975

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY4666 , 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)





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