Provider Demographics
NPI:1639325186
Name:PSYCHOLOGY CENTER FOR WELLNESS LLC
Entity Type:Organization
Organization Name:PSYCHOLOGY CENTER FOR WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-810-8110
Mailing Address - Street 1:308 E OAK AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-2344
Mailing Address - Country:US
Mailing Address - Phone:813-810-8110
Mailing Address - Fax:813-225-5678
Practice Address - Street 1:308 E OAK AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-2344
Practice Address - Country:US
Practice Address - Phone:813-810-8110
Practice Address - Fax:813-225-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6542103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54803OtherBSFL