Provider Demographics
NPI:1437754876
Name:CLINICAL PSYCHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:CLINICAL PSYCHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:850-319-9102
Mailing Address - Street 1:201 S SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4313
Mailing Address - Country:US
Mailing Address - Phone:850-319-9102
Mailing Address - Fax:
Practice Address - Street 1:913 GULF BREEZE PKWY STE 36
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4729
Practice Address - Country:US
Practice Address - Phone:850-319-9102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty