Provider Demographics
NPI:1922200278
Name:PSYCHOLOGY ASSOCIATES OF BREVARD PLC
Entity Type:Organization
Organization Name:PSYCHOLOGY ASSOCIATES OF BREVARD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-751-1925
Mailing Address - Street 1:6767 N WICKHAM RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2031
Mailing Address - Country:US
Mailing Address - Phone:321-751-1925
Mailing Address - Fax:321-751-9261
Practice Address - Street 1:6767 N WICKHAM RD
Practice Address - Street 2:SUITE 306
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2031
Practice Address - Country:US
Practice Address - Phone:321-751-1925
Practice Address - Fax:321-751-9261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5001101YM0800X
FLMH3865101YM0800X
FLPY7627103G00000X
FLPY2592103TC0700X
FLPY4859103TC0700X
2084P0800X
FLME790362084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59328YMedicare ID - Type UnspecifiedROBERT J. SHAPIRO, PH.D.
FLK1332Medicare ID - Type UnspecifiedSHAPIRO, P.A.