MEDICARE: DR. GLENN ROSS CADDY 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	PY2093	FL

General Provider Information

NPI Number	:	1497926687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN ROSS CADDY PH.D.

Provider Business Mailing Address
First Line	:	3101 NORTH FEDERAL HIGHWAY
Second Line	:	SUITE 301
City	:	FT. LAUDERDALE
State	:	FL
Zip	:	33306
Country	:	US
Telephone Number	:	954-565-8850
Fax Number	:	954-565-9860

Provider Business Practice Location Address
First Line	:	3101 NORTH FEDERAL HIGHWAY
Second Line	:	SUITE 301
City	:	FT. LAUDERDALE
State	:	FL
Zip	:	33306
Country	:	US
Telephone Number	:	954-565-8850
Fax Number	:	954-565-9860

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

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	03/17/2008

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