Healthcare Provider Details

I. General information

NPI: 1184290868
Provider Name (Legal Business Name): PSYCHOTHERAPEUTIC SERVICES OF FLORIDA, IN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 NW FEDERAL HWY STE 101
STUART FL
34994-1061
US

IV. Provider business mailing address

870 HIGH ST STE 2
CHESTERTOWN MD
21620-3914
US

V. Phone/Fax

Practice location:
  • Phone: 772-692-5566
  • Fax:
Mailing address:
  • Phone: 410-788-1099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: RANDALL COOPER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 410-810-2468