Healthcare Provider Details

I. General information

NPI: 1639203763
Provider Name (Legal Business Name): FAMILY PSYCHOLOGICAL SERVICES OF PALM HARBOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 ALT 19 STE C1
PALM HARBOR FL
34683-5361
US

IV. Provider business mailing address

2142 ALT 19 STE C1
PALM HARBOR FL
34683-5361
US

V. Phone/Fax

Practice location:
  • Phone: 727-787-6177
  • Fax: 727-787-8406
Mailing address:
  • Phone: 727-787-6177
  • Fax: 727-787-8406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY5165
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC L ROSEN
Title or Position: OWNER & PRESIDENT
Credential: PH.D.
Phone: 727-787-6177