=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902528599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENTAE PSYCHOLOGICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2022
-----------------------------------------------------
Last Update Date | 08/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6600 MAIN ST APT 1304
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-2288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-515-4519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6600 MAIN ST APT 1304
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-2288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-515-4519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMANDA M MOLES
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 305-557-6755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------