Provider Demographics
NPI:1922496850
Name:FLORIDA PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FLORIDA PSYCHOLOGICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:H
Authorized Official - Last Name:DREW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-277-0027
Mailing Address - Street 1:1903 ISLAND WALK WAY
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4797
Mailing Address - Country:US
Mailing Address - Phone:904-277-0027
Mailing Address - Fax:
Practice Address - Street 1:1903 ISLAND WALK WAY
Practice Address - Street 2:
Practice Address - City:FERNANDINA
Practice Address - State:FL
Practice Address - Zip Code:32034-4797
Practice Address - Country:US
Practice Address - Phone:904-277-0027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 261QM0801X
FLATN 581436251S00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLATN 581436Medicaid