MEDICARE: PSYCHOLOGICAL MANAGEMENT GROUP, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	PY4542	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	94978	OTHER	FL	BC BS

General Provider Information

NPI Number	:	1144384264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGICAL MANAGEMENT GROUP, PA

Provider Business Mailing Address
First Line	:	15436 N FLORIDA AVE STE 102
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-1225
Country	:	US
Telephone Number	:	813-963-1016
Fax Number	:	813-961-6591

Provider Business Practice Location Address
First Line	:	15436 N FLORIDA AVE STE 102
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-1225
Country	:	US
Telephone Number	:	813-963-1016
Fax Number	:	813-961-6591

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. ROBERT C. WRIGHT
Credential	:	PH.D.
Telephone Number	:	813-963-1016

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	05/21/2012

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