=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851082374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHCONCEPTS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2023
-----------------------------------------------------
Last Update Date | 05/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4591 E HIGHWAY 20 STE 202H
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-8854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-223-1727
-----------------------------------------------------
Fax | 561-584-7551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6619 S DIXIE HWY # 196
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-7919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-223-1727
-----------------------------------------------------
Fax | 561-584-7551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISTINE JEAN
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 561-223-1727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------