Provider Demographics
NPI:1144384264
Name:PSYCHOLOGICAL MANAGEMENT GROUP, PA
Entity Type:Organization
Organization Name:PSYCHOLOGICAL MANAGEMENT GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-963-1016
Mailing Address - Street 1:15436 N FLORIDA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1225
Mailing Address - Country:US
Mailing Address - Phone:813-963-1016
Mailing Address - Fax:813-961-6591
Practice Address - Street 1:15436 N FLORIDA AVE STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1225
Practice Address - Country:US
Practice Address - Phone:813-963-1016
Practice Address - Fax:813-961-6591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4542103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94978OtherBC BS
FL94978OtherBC BS