Healthcare Provider Details

I. General information

NPI: 1346977311
Provider Name (Legal Business Name): MELBOURNE MEDPSYCH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 OAK STREET
MELBOURNE FL
32901
US

IV. Provider business mailing address

406 AVENUE B
MELBOURNE BEACH FL
32951-2215
US

V. Phone/Fax

Practice location:
  • Phone: 540-447-0134
  • Fax: 540-932-7611
Mailing address:
  • Phone: 540-447-0134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GERALD R SHOWALTER
Title or Position: MBR
Credential: PSY.D.
Phone: 540-447-0134