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General NPI Number Information
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NPI Number | 1417111782
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Entity Type | Organization
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Legal Business Name | ESTE LOGIC, P.A.
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Dates
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Enumeration Date | 07/15/2008
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Last Update Date | 08/23/2012
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Provider Practice Location Address
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Address Line | 4020 SUN CITY CENTER BLVD SUITE 11
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City | SUN CITY CENTER
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State | FL
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Zip | 33573-5285
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Country | US
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Telephone | 813-634-4700
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Fax | 813-634-4703
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Provider Business Mailing Address
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Address Line | 4020 SUN CITY CENTER BLVD SUITE 11
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City | SUN CITY CENTER
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State | FL
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Zip | 33573-5285
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Country | US
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Telephone | 813-634-4700
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Fax | 813-634-4703
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. ESTELA LONG
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Credential | PSY.D.
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Telephone | 813-728-3521
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY6533
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License Number State | FL
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