Healthcare Provider Details

I. General information

NPI: 1285094177
Provider Name (Legal Business Name): CORNELIA IUCHA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 RAYMOND STREET ORLANDO VA MEDICAL CENTER LAKE BALDWIN OPC MENTAL HEALTH, ROOM 422
ORLANDO FL
32803
US

IV. Provider business mailing address

2501 RAYMOND STREET ORLANDO VA MEDICAL CENTER LAKE BALDWIN OPC MENTAL HEALTH, ROOM 422
ORLANDO FL
32803
US

V. Phone/Fax

Practice location:
  • Phone: 407-646-5500
  • Fax: 407-513-9328
Mailing address:
  • Phone: 407-646-5500
  • Fax: 407-513-9328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005492
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: