Provider Demographics
NPI:1417211723
Name:HERSHEY, ILYSSA (PSYD)
Entity Type:Individual
Prefix:
First Name:ILYSSA
Middle Name:
Last Name:HERSHEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4581 WESTON ROAD
Mailing Address - Street 2:PMB 351
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3141
Mailing Address - Country:US
Mailing Address - Phone:954-849-2012
Mailing Address - Fax:754-229-8251
Practice Address - Street 1:2855 N UNIVERSITY DR
Practice Address - Street 2:STE 410
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-1408
Practice Address - Country:US
Practice Address - Phone:954-849-2012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2016-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6625103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical