MEDICARE: DR. LONNY C WEISS PSYD

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	103TC0700X	Clinical Psychologist	PY6534	FL
2	103TC1900X	Counseling Psychologist	PY6534	FL
3	103TC2200X	Clinical Child & Adolescent Psychologist	PY6534	FL
4	103T00000X	Psychologist	PY6534	FL

General Provider Information

NPI Number	:	1154319655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LONNY C WEISS PSYD

Provider Business Mailing Address
First Line	:	4362 NORTHLAKE BLVD
Second Line	:	SUITE 208
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-6275
Country	:	US
Telephone Number	:	561-630-0865
Fax Number	:	561-630-0866

Provider Business Practice Location Address
First Line	:	4362 NORTHLAKE BLVD
Second Line	:	SUITE 208
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-6275
Country	:	US
Telephone Number	:	561-630-0865
Fax Number	:	561-630-0866

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	05/18/2021

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