Healthcare Provider Details

I. General information

NPI: 1154892966
Provider Name (Legal Business Name): JUSTIN MICHAEL PUDER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W CAMINO REAL STE 201
BOCA RATON FL
33432-5966
US

IV. Provider business mailing address

8639 EAGLE RUN DR APT 11
BOCA RATON FL
33434-5439
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 330-620-8352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY10018
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: