Provider Demographics
NPI:1760708754
Name:SOUTH MIAMI PSYCHOLOGY GROUP
Entity Type:Organization
Organization Name:SOUTH MIAMI PSYCHOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:L
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:305-662-2686
Mailing Address - Street 1:1390 S DIXIE HWY STE 1305
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2974
Mailing Address - Country:US
Mailing Address - Phone:305-662-2686
Mailing Address - Fax:305-662-7091
Practice Address - Street 1:1390 S DIXIE HWY STE 1305
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2974
Practice Address - Country:US
Practice Address - Phone:305-662-2686
Practice Address - Fax:305-662-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7923103TC1900X
FLPY 5818103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty