=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801247804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUDREY CLEARY, PH.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2016
-----------------------------------------------------
Last Update Date | 09/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5915 PONCE DE LEON BLVD SUITE 19
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33146-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-767-1108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5915 PONCE DE LEON BLVD SUITE 19
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33146-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-767-1108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | AUDREY CLEARY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 305-767-1108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY8599
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------