=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831381722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH WM NUSSBAUMER JR. PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 08/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 627 S MAIN AVE
-----------------------------------------------------
City | GROVELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34736-2731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-429-5600
-----------------------------------------------------
Fax | 352-429-1206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 627 S MAIN AVE
-----------------------------------------------------
City | GROVELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34736-2731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-429-5600
-----------------------------------------------------
Fax | 352-429-1206
-----------------------------------------------------
=====================================================
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 | CPY0003010493-FACCT
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------