Healthcare Provider Details

I. General information

NPI: 1003149576
Provider Name (Legal Business Name): MICHAEL J. BACHOP PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 N 12TH AVE BLDG B
ARCADIA FL
34266-8752
US

IV. Provider business mailing address

700 8TH AVE W STE 101
PALMETTO FL
34221-4737
US

V. Phone/Fax

Practice location:
  • Phone: 941-776-4000
  • Fax:
Mailing address:
  • Phone: 941-776-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number2009026784
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2009026784
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2009026784
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number2009026784
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY11082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: