Provider Demographics
NPI:1013202571
Name:THOMAS F. GUIDERA, PH.D, P.A.
Entity Type:Organization
Organization Name:THOMAS F. GUIDERA, PH.D, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUIDERA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PA
Authorized Official - Phone:321-268-5682
Mailing Address - Street 1:1777 GARDEN STREET
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3221
Mailing Address - Country:US
Mailing Address - Phone:321-268-5682
Mailing Address - Fax:321-268-5683
Practice Address - Street 1:1777 GARDEN STREET
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3221
Practice Address - Country:US
Practice Address - Phone:321-268-5682
Practice Address - Fax:321-268-5683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 3165103T00000X
FLPY0003165103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1770647810OtherCURRENT NPI
75434OtherMEDICARE PTAN
1770647810OtherCURRENT NPI