Provider Demographics
NPI:1639203763
Name:FAMILY PSYCHOLOGICAL SERVICES OF PALM HARBOR INC
Entity Type:Organization
Organization Name:FAMILY PSYCHOLOGICAL SERVICES OF PALM HARBOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:727-787-6177
Mailing Address - Street 1:2142 ALT 19 STE C1
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-5361
Mailing Address - Country:US
Mailing Address - Phone:727-787-6177
Mailing Address - Fax:727-787-8406
Practice Address - Street 1:2142 ALT 19 STE C1
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-5361
Practice Address - Country:US
Practice Address - Phone:727-787-6177
Practice Address - Fax:727-787-8406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5165103T00000X
103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4176Medicare PIN