=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902801210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY AREA PSYCHOLOGICAL CONSULTANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2005
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1417 PARTIN DR N STE 1
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-729-0303
-----------------------------------------------------
Fax | 850-729-0305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1417 PARTIN DR N STE 1
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-729-0303
-----------------------------------------------------
Fax | 850-729-0305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL L TALLMAN
-----------------------------------------------------
Credential | PSY.D
-----------------------------------------------------
Telephone | 850-729-0303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY7250
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY5264
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY4031
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY4285
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------