Provider Demographics
NPI:1922474907
Name:NEUROGENESIS CENTER OF FLORIDA, PLLC
Entity Type:Organization
Organization Name:NEUROGENESIS CENTER OF FLORIDA, PLLC
Other - Org Name:AMBER FASULA, PSY.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:L
Authorized Official - Last Name:FASULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-790-4101
Mailing Address - Street 1:253 N ORLANDO AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5521
Mailing Address - Country:US
Mailing Address - Phone:407-790-4101
Mailing Address - Fax:407-277-4400
Practice Address - Street 1:253 N ORLANDO AVE STE 202
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5521
Practice Address - Country:US
Practice Address - Phone:407-790-4101
Practice Address - Fax:407-277-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-13
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9333103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty