Healthcare Provider Details

I. General information

NPI: 1811133309
Provider Name (Legal Business Name): SRM CLINICAL PSYCHOLOGY P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 HOLLYWOOD BLVD SUITE 201
HOLLYWOOD FL
33024-7900
US

IV. Provider business mailing address

3215 NE 184TH ST APTO 14203
NORTH MIAMI BEACH FL
33160-4994
US

V. Phone/Fax

Practice location:
  • Phone: 954-962-8052
  • Fax: 954-966-4774
Mailing address:
  • Phone: 954-962-8052
  • Fax: 954-966-4774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number7360
License Number StateFL

VIII. Authorized Official

Name: SARA MALAGOLD
Title or Position: PRESIDENT
Credential:
Phone: 954-962-8052