MEDICARE: EXPERT PSYCHOLOGICAL ASSOCIATES, LLC

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	103TF0200X	Forensic Psychologist	PY8016	FL
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
3	103TC0700X	Clinical Psychologist	PY8016	FL

General Provider Information

NPI Number	:	1306133244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPERT PSYCHOLOGICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	447 NW PRIMA VISTA BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-8731
Country	:	US
Telephone Number	:	772-249-2593
Fax Number	:

Provider Business Practice Location Address
First Line	:	447 NW PRIMA VISTA BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-8731
Country	:	US
Telephone Number	:	772-249-2593
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST/PRESIDENT
Name	:	DR. GEORGE ZAKY
Credential	:	PSY.D.
Telephone Number	:	772-249-2593

Provider Enumeration Date	:	06/29/2011
Last Update Date	:	06/16/2018

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