Healthcare Provider Details

I. General information

NPI: 1881908689
Provider Name (Legal Business Name): NORTHWEST FLORIDA PSYCHOLOGICAL SERVICES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MARY ESTHER BLVD STE 308A
MARY ESTHER FL
32569-1972
US

IV. Provider business mailing address

519 BOULDER ST
CRESTVIEW FL
32536-2251
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-7322
  • Fax: 850-226-7491
Mailing address:
  • Phone: 850-226-7322
  • Fax: 850-226-7491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY0007168
License Number StateFL

VIII. Authorized Official

Name: DR. JULIE HARPER
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSY.D.
Phone: 850-226-7322