Healthcare Provider Details

I. General information

NPI: 1669798278
Provider Name (Legal Business Name): SHIP PORT PSYCH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5637 MARINE PKWY
NEW PORT RICHEY FL
34652-4316
US

IV. Provider business mailing address

13737 NOEL RD STE 1600
DALLAS TX
75240-1331
US

V. Phone/Fax

Practice location:
  • Phone: 727-834-5744
  • Fax: 727-834-5717
Mailing address:
  • Phone: 469-401-2386
  • Fax: 214-712-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KATHY KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132