=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750819066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL THOMAS PLASAY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2017
-----------------------------------------------------
Last Update Date | 05/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2056 CENTRE POINTE LN
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-877-9355
-----------------------------------------------------
Fax | 850-552-0608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 REVELL RD
-----------------------------------------------------
City | CRAWFORDVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32327-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 18506318660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 9050
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------