=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457656134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PALIKA TRUDEAU M.A. PSYCHOLOGY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2011
-----------------------------------------------------
Last Update Date | 01/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14616 NW 140TH ST
-----------------------------------------------------
City | ALACHUA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32615-6261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-283-3102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 44
-----------------------------------------------------
City | ALACHUA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32616-0044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-283-3102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | IMT 887
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------