MEDICARE: RICHARD K WILLENS PSY.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	PY4820	FL

General Provider Information

NPI Number	:	1679627475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD K WILLENS PSY.D

Provider Business Mailing Address
First Line	:	1155 LOUISIANA AVE STE 106
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-2351
Country	:	US
Telephone Number	:	407-629-4356
Fax Number	:	407-629-1812

Provider Business Practice Location Address
First Line	:	1155 LOUISIANA AVE STE 106
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-2351
Country	:	US
Telephone Number	:	407-629-4356
Fax Number	:	407-629-1812

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/08/2007

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