=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508005869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARTA MANRIQUE-REICHARD, PH. D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2009
-----------------------------------------------------
Last Update Date | 04/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5940 SW 73RD ST SUITE 203
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-669-0019
-----------------------------------------------------
Fax | 305-669-0029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5940 SW 73RD ST SUITE 203
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-669-0019
-----------------------------------------------------
Fax | 305-669-0029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MARTA ELENA MANRIQUE-REICHARD
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 305-669-0019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY5809
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------