1679693121 NPI number — CARY R SHOOKOFF PHD PSYCHOLOGIST LLC

Table of content: (NPI 1679693121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679693121 NPI number — CARY R SHOOKOFF PHD PSYCHOLOGIST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARY R SHOOKOFF PHD PSYCHOLOGIST 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:
1679693121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 PURDY AVE STE 2
Provider Second Line Business Mailing Address:
COMM. UNITS G & G
Provider Business Mailing Address City Name:
MIAMI BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33139-1409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-674-0055
Provider Business Mailing Address Fax Number:
305-341-3935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 PURDY AVE STE 2
Provider Second Line Business Practice Location Address:
COMM. UNITS G & G
Provider Business Practice Location Address City Name:
MIAMI BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33139-1409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-674-0055
Provider Business Practice Location Address Fax Number:
305-341-3935
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHOOKOFF
Authorized Official First Name:
CARY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DIRECTOR PRESIDENT PSYCHOLOGIST
Authorized Official Telephone Number:
305-674-0055

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PY 2924 , 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: 59 2398787 . This is a "FEDERAL TAX ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 73236 . This is a "BLUE CROSS - MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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