Healthcare Provider Details

I. General information

NPI: 1144384264
Provider Name (Legal Business Name): PSYCHOLOGICAL MANAGEMENT GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15436 N FLORIDA AVE STE 102
TAMPA FL
33613-1225
US

IV. Provider business mailing address

15436 N FLORIDA AVE STE 102
TAMPA FL
33613-1225
US

V. Phone/Fax

Practice location:
  • Phone: 813-963-1016
  • Fax: 813-961-6591
Mailing address:
  • Phone: 813-963-1016
  • Fax: 813-961-6591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY4542
License Number StateFL

VIII. Authorized Official

Name: DR. ROBERT C. WRIGHT
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 813-963-1016