Healthcare Provider Details

I. General information

NPI: 1760435754
Provider Name (Legal Business Name): MARY DEAN ATWOOD PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 OAKHURST DR
SARASOTA FL
34233-1444
US

IV. Provider business mailing address

4070 OAKHURST DR
SARASOTA FL
34233-1444
US

V. Phone/Fax

Practice location:
  • Phone: 941-487-7890
  • Fax: 941-487-7890
Mailing address:
  • Phone: 941-487-7890
  • Fax: 941-487-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number550
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number550
License Number StateNM

VIII. Authorized Official

Name: MARY DEAN ATWOOD
Title or Position: PRESIDENT/PSYCHOLOGIST
Credential: PHD
Phone: 941-487-7890