MEDICARE: DR. CORISSA LYNN BAYER PH.D.

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	3571	GA
2	103TC0700X	Clinical Psychologist	PY9441	FL
3	103TC0700X	Clinical Psychologist	PY9440	FL

General Provider Information

NPI Number	:	1790029783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORISSA LYNN BAYER PH.D.

Provider Business Mailing Address
First Line	:	3 VINE AVE NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5069
Country	:	US
Telephone Number	:	850-226-7666
Fax Number	:	850-226-7499

Provider Business Practice Location Address
First Line	:	3 VINE AVE NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5069
Country	:	US
Telephone Number	:	850-226-7666
Fax Number	:	850-226-7499

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/25/2019

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