=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306947809
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARA MATILE HENDRY PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 05/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5348 1ST AVE N SUITE D
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-8106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-322-6123
-----------------------------------------------------
Fax | 727-322-6143
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 47918
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-322-6123
-----------------------------------------------------
Fax | 727-322-6143
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY6690
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------