Healthcare Provider Details

I. General information

NPI: 1679537625
Provider Name (Legal Business Name): FRED WILLIAM THEYE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13416 HARBOUR RIDGE BLVD
PALM CITY FL
34990-4814
US

IV. Provider business mailing address

850 NW FEDERAL HWY STE 170
STUART FL
34994-1019
US

V. Phone/Fax

Practice location:
  • Phone: 772-644-6456
  • Fax:
Mailing address:
  • Phone: 772-985-0116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY 6904
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: