=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265487243
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVERY RUBIN PH D PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 02/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22047 STATE ROAD 7
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33428-4219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-695-3227
-----------------------------------------------------
Fax | 954-472-3710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10320 NW 14TH ST
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33322-6607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-695-3227
-----------------------------------------------------
Fax | 954-472-3710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AVERY RUBIN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 954-695-3227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY0004523
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------