Healthcare Provider Details

I. General information

NPI: 1417948993
Provider Name (Legal Business Name): MADELINE ALTABE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7747 MITCHELL BLVD STE B
TRINITY FL
34655-4725
US

IV. Provider business mailing address

7747 MITCHELL BLVD STE B
TRINITY FL
34655-4725
US

V. Phone/Fax

Practice location:
  • Phone: 404-941-6402
  • Fax:
Mailing address:
  • Phone: 404-941-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPY4848
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY4848
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: