Healthcare Provider Details

I. General information

NPI: 1558476861
Provider Name (Legal Business Name): DAVID LEWIS SLACK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10,000 BAY PINES BLVD.
BAY PINES FL
33744
US

IV. Provider business mailing address

8144 128TH ST
SEMINOLE FL
33776-3605
US

V. Phone/Fax

Practice location:
  • Phone: 727-398-6661
  • Fax:
Mailing address:
  • Phone: 727-393-0248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY5032
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPY5032
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY5032
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPY5032
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: