MEDICARE: DR. THOMAS F GUIDERA 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	PY0003165	FL

General Provider Information

NPI Number	:	1770647810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS F GUIDERA PH.D.

Provider Business Mailing Address
First Line	:	1777 GARDEN ST
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32796-3221
Country	:	US
Telephone Number	:	321-268-5682
Fax Number	:	321-268-5683

Provider Business Practice Location Address
First Line	:	1777 GARDEN ST
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32796-3221
Country	:	US
Telephone Number	:	321-268-5682
Fax Number	:	321-268-5683

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

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	07/08/2007

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