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General NPI Number Information
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NPI Number | 1154892966
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Entity Type | Individual
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Provider Name | JUSTIN MICHAEL PUDER PHD
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Gender | Male
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Dates
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Enumeration Date | 12/06/2018
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Last Update Date | 12/06/2018
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Provider Practice Location Address
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Address Line | 1 W CAMINO REAL STE 201
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City | BOCA RATON
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State | FL
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Zip | 33432-5966
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Country | US
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Telephone |
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Fax |
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Provider Business Mailing Address
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Address Line | 8639 EAGLE RUN DR APT 11
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City | BOCA RATON
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State | FL
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Zip | 33434-5439
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Country | US
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Telephone | 330-620-8352
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | PY10018
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License Number State | FL
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