MEDICARE: DR. NATHALY SHOUA DESMARAIS 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	103T00000X	Psychologist	PY7955	FL

General Provider Information

NPI Number	:	1891928420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHALY SHOUA DESMARAIS PSY.D.

Provider Business Mailing Address
First Line	:	3000 SW 121ST AVE
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33330-1318
Country	:	US
Telephone Number	:	954-600-9190
Fax Number	:	954-473-4267

Provider Business Practice Location Address
First Line	:	5400 S UNIVERSITY DR
Second Line	:	SUITE 119
City	:	DAVIE
State	:	FL
Zip	:	33328-5312
Country	:	US
Telephone Number	:	954-600-9190
Fax Number	:

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

Provider Enumeration Date	:	08/31/2009
Last Update Date	:	08/31/2009

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