=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659784775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISRA SALEH-MOHD, PSY.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2014
-----------------------------------------------------
Last Update Date | 06/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 LITHIA PINECREST RD
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-6138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-541-3372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1327 GARDEN STONE LN
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33510-2654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-541-3372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ISRA SALEH-MOHD
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 813-541-3372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY7588
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------