=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730224403
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TARPON PSYCHIATRIC CENTER, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 S PINELLAS AVE SUITE K
-----------------------------------------------------
City | TARPON SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34689-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-938-0714
-----------------------------------------------------
Fax | 727-938-9513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 S PINELLAS AVE SUITE K
-----------------------------------------------------
City | TARPON SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34689-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-938-0714
-----------------------------------------------------
Fax | 727-938-9513
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. IRENE ANDREA NICKOLAKIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 727-938-0714
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME0055877
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------