Provider Demographics
NPI:1689002362
Name:PSY-CREST PSYCHOLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:PSY-CREST PSYCHOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-346-1634
Mailing Address - Street 1:4213 SUMMIT CREEK BLVD APT 7107
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-4503
Mailing Address - Country:US
Mailing Address - Phone:850-346-1634
Mailing Address - Fax:
Practice Address - Street 1:4213 SUMMIT CREEK BLVD APT 7107
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-4503
Practice Address - Country:US
Practice Address - Phone:850-346-1634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8870103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty