MEDICARE: CORAL PSYCHOLOGICAL SERVICES, PLLC

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	251S00000X	Community/Behavioral Health Agency	PY7558	FL

General Provider Information

NPI Number	:	1538583497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORAL PSYCHOLOGICAL SERVICES, PLLC

Provider Business Mailing Address
First Line	:	2804 DEL PRADO BLVD S
Second Line	:	202-4
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-7252
Country	:	US
Telephone Number	:	239-645-1847
Fax Number	:	239-829-0323

Provider Business Practice Location Address
First Line	:	2804 DEL PRADO BLVD S
Second Line	:	202-4
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-7252
Country	:	US
Telephone Number	:	239-645-1847
Fax Number	:	239-829-0323

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. PAULINE JULIE HIGHTOWER
Credential	:	PSY.D
Telephone Number	:	239-645-1847

Provider Enumeration Date	:	02/13/2014
Last Update Date	:	07/16/2014

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