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General NPI Number Information
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NPI Number | 1972088912
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Entity Type | Organization
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Legal Business Name | COLLABORATIVE PSYCH & MED
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Dates
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Enumeration Date | 09/26/2018
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Last Update Date | 09/26/2018
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Provider Practice Location Address
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Address Line | 4406 S FLORIDA AVE STE 31
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City | LAKELAND
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State | FL
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Zip | 33813-2176
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Country | US
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Telephone | 855-732-5292
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Fax | 863-583-9926
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Provider Business Mailing Address
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Address Line | 4406 S FLORIDA AVE STE 31
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City | LAKELAND
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State | FL
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Zip | 33813-2176
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Country | US
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Telephone | 855-732-5292
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Fax | 863-583-9926
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KELLY WOOD
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Credential | BSW
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Telephone | 855-732-5292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0700X
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Taxonomy Name | Adult Development & Aging Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number |
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License Number State |
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