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General NPI Number Information
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NPI Number | 1780864223
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Entity Type | Organization
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Legal Business Name | CENTER FOR PSYCHOLOGICAL SERVICES INC
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Dates
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Enumeration Date | 11/13/2007
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Last Update Date | 12/15/2010
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Provider Practice Location Address
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Address Line | 4256 WICKS BRANCH RD
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32086-5568
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Country | US
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Telephone | 904-269-6677
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Fax | 904-269-6677
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Provider Business Mailing Address
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Address Line | PO BOX 1556
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City | ORANGE PARK
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State | FL
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Zip | 32067-1556
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Country | US
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Telephone | 904-269-6677
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Fax | 904-269-6677
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEITH ROCKY D'AMATO
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Credential | PH.D.
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Telephone | 904-269-6677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY3352
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License Number State | FL
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