Healthcare Provider Details

I. General information

NPI: 1962696955
Provider Name (Legal Business Name): PRIMARY CARE PSYCHOLOGY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2007
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 N FEDERAL HWY SUITE C
POMPANO BEACH FL
33062-1032
US

IV. Provider business mailing address

1990 N FEDERAL HWY SUITE C
POMPANO BEACH FL
33062-1032
US

V. Phone/Fax

Practice location:
  • Phone: 954-788-9399
  • Fax: 954-905-4990
Mailing address:
  • Phone: 954-788-9399
  • Fax: 954-905-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6322
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPY6322
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberPY6322
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberPY6322
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberPY6322
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPY6322
License Number StateFL

VIII. Authorized Official

Name: DR. MICHAEL CRISTIANO
Title or Position: PSYCHOLOGIST
Credential: PSY.D.
Phone: 954-788-9399