Provider Demographics
NPI:1821629593
Name:PROFESSIONAL PSYCHOLOGICAL SERVICES OF FLORIDA
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHOLOGICAL SERVICES OF FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KLUKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:813-351-9235
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-0441
Mailing Address - Country:US
Mailing Address - Phone:813-351-9235
Mailing Address - Fax:
Practice Address - Street 1:15525 STARLING CROSSING DR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-4021
Practice Address - Country:US
Practice Address - Phone:813-351-9235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-30
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty