Provider Demographics
NPI:1134633092
Name:BERCAW NEUROPSYCHOLOGY
Entity type:Organization
Organization Name:BERCAW NEUROPSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERCAW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-603-7635
Mailing Address - Street 1:710 OAKFIELD DR STE 153
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4954
Mailing Address - Country:US
Mailing Address - Phone:813-603-7635
Mailing Address - Fax:813-501-1186
Practice Address - Street 1:710 OAKFIELD DR STE 153
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4954
Practice Address - Country:US
Practice Address - Phone:813-603-7635
Practice Address - Fax:813-501-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-29
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7991103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5932XOtherFLORIDA BLUE