=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972939767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRED J. RAHAIM, PH.D. P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2013
-----------------------------------------------------
Last Update Date | 09/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5635 CREST CREEK DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-5358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-704-0851
-----------------------------------------------------
Fax | 904-880-0652
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5635 CREST CREEK DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-5358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-704-0851
-----------------------------------------------------
Fax | 904-880-0652
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. FRED JOSEPH RAHAIM
-----------------------------------------------------
Credential | PH.,D.
-----------------------------------------------------
Telephone | 904-704-0851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY00002524
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------