Provider Demographics
NPI:1407398753
Name:TEMPLE, PHILYCE
Entity Type:Individual
Prefix:
First Name:PHILYCE
Middle Name:
Last Name:TEMPLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4094
Mailing Address - Country:US
Mailing Address - Phone:407-721-1774
Mailing Address - Fax:
Practice Address - Street 1:324 NEWBURYPORT AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-3645
Practice Address - Country:US
Practice Address - Phone:407-807-6402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL1-18-33186103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020597700Medicaid
FL025097700Medicaid