=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063050359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL PLASENCIA, PSYD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2019
-----------------------------------------------------
Last Update Date | 12/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10406 TAFT ST
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-2819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-436-3880
-----------------------------------------------------
Fax | 954-436-3881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10406 TAFT ST
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-2819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-436-3880
-----------------------------------------------------
Fax | 954-436-3881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL ANTHONY PLASENCIA
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 954-559-9201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------