MEDICARE: PSYCHOLOGY CENTER FOR WELLNESS 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	103T00000X	Psychologist	PY6542	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	54803	OTHER	FL	BSFL

General Provider Information

NPI Number	:	1639325186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGY CENTER FOR WELLNESS LLC

Provider Business Mailing Address
First Line	:	308 E OAK AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-2344
Country	:	US
Telephone Number	:	813-810-8110
Fax Number	:	813-225-5678

Provider Business Practice Location Address
First Line	:	308 E OAK AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-2344
Country	:	US
Telephone Number	:	813-810-8110
Fax Number	:	813-225-5678

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT J PORTER
Credential	:	PHD
Telephone Number	:	813-810-8110

Provider Enumeration Date	:	08/15/2008
Last Update Date	:	08/15/2008

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