=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982816856
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RALPH J DOLENTE PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 N CENTRAL AVE
-----------------------------------------------------
City | BARTOW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33830-4742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-534-3017
-----------------------------------------------------
Fax | 863-534-8008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2301 GATEWOOD ST
-----------------------------------------------------
City | PLANT CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33563-8832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-534-3017
-----------------------------------------------------
Fax | 863-534-8008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PY4209
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------