MEDICARE: JOHN HENDERSHOT, PH.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY4314	FL

General Provider Information

NPI Number	:	1134293343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN HENDERSHOT, PH.D., P.A.

Provider Business Mailing Address
First Line	:	5221 EHRLICH RD STE A
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-2006
Country	:	US
Telephone Number	:	813-265-4811
Fax Number	:	813-277-0202

Provider Business Practice Location Address
First Line	:	5221 EHRLICH RD
Second Line	:	SUITE A
City	:	TAMPA
State	:	FL
Zip	:	33624-2006
Country	:	US
Telephone Number	:	813-265-4811
Fax Number	:	813-277-0202

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN HENDERSHOT
Credential	:	PH.D.
Telephone Number	:	813-265-4811

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	08/22/2020

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