Provider Demographics
NPI:1679242648
Name:TAMPA PALMS PSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:TAMPA PALMS PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:727-239-5684
Mailing Address - Street 1:17401 COMMERCE PARK BLVD STE 103-0319
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3501
Mailing Address - Country:US
Mailing Address - Phone:727-239-5684
Mailing Address - Fax:
Practice Address - Street 1:16203 HAMPTON TRACE CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2745
Practice Address - Country:US
Practice Address - Phone:727-239-5684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-12
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health