Provider Demographics
NPI:1790839769
Name:WOULAS, MICHAEL JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:WOULAS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8870 TERRENE CT
Mailing Address - Street 2:#102
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-9524
Mailing Address - Country:US
Mailing Address - Phone:239-949-2415
Mailing Address - Fax:239-390-1327
Practice Address - Street 1:8870 TERRENE CT
Practice Address - Street 2:#102
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-9524
Practice Address - Country:US
Practice Address - Phone:239-949-2415
Practice Address - Fax:239-390-1327
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0978103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL283561Medicaid
FL240441Medicaid