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General NPI Number Information
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NPI Number | 1811308901
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Entity Type | Organization
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Legal Business Name | JANICE WACHTEL, PHD, LLC
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Dates
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Enumeration Date | 05/12/2014
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Last Update Date | 07/22/2016
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Provider Practice Location Address
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Address Line | 100 EXECUTIVE WAY, SUITE 110
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082
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Country | US
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Telephone | 904-834-2235
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Fax | 904-834-3520
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Provider Business Mailing Address
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Address Line | 100 EXECUTIVE WAY, SUITE 110
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082
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Country | US
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Telephone | 904-834-2235
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Fax | 904-834-3520
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. JANICE WACHTEL
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Credential | PH.D.
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Telephone | 904-834-2235
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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 | P40005827
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License Number State | FL
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