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General NPI Number Information
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NPI Number | 1891732632
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Entity Type | Individual
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Provider Name | HOMER E. FOUTY JR. PH.D.
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Gender | Male
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Dates
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Enumeration Date | 06/01/2006
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Last Update Date | 03/29/2018
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Provider Practice Location Address
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Address Line | 301 MEMORIAL MEDICAL PKWY
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City | DAYTONA BEACH
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State | FL
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Zip | 32117-5167
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Country | US
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Telephone | 386-231-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 361 COLLINS ST
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City | ORMOND BEACH
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State | FL
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Zip | 32174-6906
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Country | US
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Telephone | 386-682-9612
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Fax | 386-615-1022
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PY5097
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY5097
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License Number State | FL
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