MEDICARE: DR. WARREN B. GRADITOR PH.D.

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	PYOO2243	FL

General Provider Information

NPI Number	:	1235108143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WARREN B. GRADITOR PH.D.

Provider Business Mailing Address
First Line	:	4400 SHERIDAN ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-3514
Country	:	US
Telephone Number	:	954-961-5447
Fax Number	:

Provider Business Practice Location Address
First Line	:	4400 SHERIDAN ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-3514
Country	:	US
Telephone Number	:	954-961-5447
Fax Number	:

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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