=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518409473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAMPA BAY PSYCHOLOGY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2016
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N BELCHER RD SUITE 100
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-792-0772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 N BELCHER RD SUITE 100
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-547-7240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. BRANDY BENSON
-----------------------------------------------------
Credential | PSY D
-----------------------------------------------------
Telephone | 954-527-7240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY9648
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------