Provider Demographics
NPI:1356409783
Name:ZWINGELBERG, MARK MANLEY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:MANLEY
Last Name:ZWINGELBERG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4503 BRANDYWOOD PLACE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801
Mailing Address - Country:US
Mailing Address - Phone:863-666-3838
Mailing Address - Fax:863-666-3838
Practice Address - Street 1:3425 LAKE ALFRED ROAD
Practice Address - Street 2:WINTER HAVEN HOSPITAL REHABILITATION SERVICES
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-292-4061
Practice Address - Fax:863-293-6985
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 3630103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75678Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER