MEDICARE: INDIVIDUALIZED PSYCHOLOGICAL RESOURCES, INC.

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	PY7215	FL

General Provider Information

NPI Number	:	1780817627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIVIDUALIZED PSYCHOLOGICAL RESOURCES, INC.

Provider Business Mailing Address
First Line	:	7476 NW 18TH DR
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-1008
Country	:	US
Telephone Number	:	954-964-2925
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 MIDDLE RIVER DR STE 307
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3560
Country	:	US
Telephone Number	:	954-632-7260
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. KITY D. LABORIEL
Credential	:	PSY.D.
Telephone Number	:	954-964-2925

Provider Enumeration Date	:	08/26/2009
Last Update Date	:	08/26/2009

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