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General NPI Number Information
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NPI Number | 1063579662
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Entity Type | Organization
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Legal Business Name | JACK R WEITZ PHD PA
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1021 IVES DAIRY RD BLDG 3 SUITE 119
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City | N MIAMI BEACH
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State | FL
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Zip | 33179
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Country | US
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Telephone | 305-655-2335
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Fax | 305-652-5759
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Provider Business Mailing Address
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Address Line | 1021 IVES DAIRY RD BLDG 3 SUITE 119
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City | N MIAMI BEACH
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State | FL
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Zip | 33179
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Country | US
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Telephone | 305-655-2335
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Fax | 305-652-5759
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Authorized Official
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Title or Position | PRESIDENT PSYCHOLOGIST
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Name | JACK ROBERT WEITZ
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Credential | PHD
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Telephone | 305-655-2335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY4345
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License Number State | FL
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