MEDICARE: PRIMARY CARE PSYCHOLOGY, PLC

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	251S00000X	Community/Behavioral Health Agency	PY6322	FL
2	261Q00000X	Clinic/Center	PY6322	FL
3	261QH0100X	Health Service Clinic/Center	PY6322	FL
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	PY6322	FL
5	261QM0850X	Adult Mental Health Clinic/Center	PY6322	FL
6	103TC0700X	Clinical Psychologist	PY6322	FL

General Provider Information

NPI Number	:	1962696955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE PSYCHOLOGY, PLC

Provider Business Mailing Address
First Line	:	1990 N FEDERAL HWY
Second Line	:	SUITE C
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-1032
Country	:	US
Telephone Number	:	954-788-9399
Fax Number	:	954-905-4990

Provider Business Practice Location Address
First Line	:	1990 N FEDERAL HWY
Second Line	:	SUITE C
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-1032
Country	:	US
Telephone Number	:	954-788-9399
Fax Number	:	954-905-4990

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. MICHAEL CRISTIANO
Credential	:	PSY.D.
Telephone Number	:	954-788-9399

Provider Enumeration Date	:	09/01/2007
Last Update Date	:	01/04/2008

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