Healthcare Provider Details

I. General information

NPI: 1699054502
Provider Name (Legal Business Name): F CHARLES MACE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 07/13/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

IV. Provider business mailing address

300 N PHILLIPS AVE APT 305
SIOUX FALLS SD
57104-6047
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-4100
  • Fax: 954-262-2271
Mailing address:
  • Phone: 207-332-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY8302
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-5055
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: