Provider Demographics
NPI:1417171208
Name:UNIVERSITY OF SOUTH FLORIDA
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTH FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:ABBY
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-975-6963
Mailing Address - Street 1:3500 E FLETCHER AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4708
Mailing Address - Country:US
Mailing Address - Phone:813-975-6963
Mailing Address - Fax:813-975-6596
Practice Address - Street 1:3500 E FLETCHER AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4708
Practice Address - Country:US
Practice Address - Phone:813-975-6963
Practice Address - Fax:813-975-6596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4230251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health