Healthcare Provider Details

I. General information

NPI: 1164591954
Provider Name (Legal Business Name): FLORIDA ATLANTIC UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 GLADES RD BLDG AZ-79
BOCA RATON FL
33431-6424
US

IV. Provider business mailing address

777 GLADES RD BLDG AZ-79
BOCA RATON FL
33431-6424
US

V. Phone/Fax

Practice location:
  • Phone: 561-297-0502
  • Fax: 561-297-0505
Mailing address:
  • Phone: 561-297-0502
  • Fax: 561-297-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LOUISA PONTIROLI-KELLY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 561-297-2897