=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114348794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CD PSYCHOLOGICAL PRACTICE, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2013
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1937 GRACE AVE STE 100
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-7119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-340-5589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118-35 QUEENS BLVD SUITE 1403
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-7205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-268-6600
-----------------------------------------------------
Fax | 718-268-6065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. CYNTHIA DAVEY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 718-268-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH 10313
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | MH 10313
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------