Healthcare Provider Details

I. General information

NPI: 1134633092
Provider Name (Legal Business Name): BERCAW NEUROPSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 OAKFIELD DR STE 153
BRANDON FL
33511-4954
US

IV. Provider business mailing address

710 OAKFIELD DR STE 153
BRANDON FL
33511-4954
US

V. Phone/Fax

Practice location:
  • Phone: 813-603-7635
  • Fax: 813-501-1186
Mailing address:
  • Phone: 813-603-7635
  • Fax: 813-501-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY7991
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7991
License Number StateFL

VIII. Authorized Official

Name: DR. EDWIN BERCAW
Title or Position: NEUROPSYCHOLOGIST
Credential: PHD
Phone: 813-603-7635