Provider Demographics
NPI:1699815753
Name:PSYCHOLOGICAL AFFILIATES INC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL AFFILIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-740-6838
Mailing Address - Street 1:2737 W FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3314
Mailing Address - Country:US
Mailing Address - Phone:407-740-6838
Mailing Address - Fax:407-740-0902
Practice Address - Street 1:2737 W FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3314
Practice Address - Country:US
Practice Address - Phone:407-740-6838
Practice Address - Fax:407-740-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1651103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21680Medicare ID - Type UnspecifiedGROUP ID