Provider Demographics
NPI:1083842900
Name:PSYCHOLOGY SERVICES ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PSYCHOLOGY SERVICES ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-810-8110
Mailing Address - Street 1:118 W PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-5752
Mailing Address - Country:US
Mailing Address - Phone:813-810-8110
Mailing Address - Fax:813-225-5678
Practice Address - Street 1:308 E OAK AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-2344
Practice Address - Country:US
Practice Address - Phone:813-810-8110
Practice Address - Fax:813-225-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
54803ZMedicare UPIN