Provider Demographics
NPI:1669963559
Name:PM PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:PM PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-222-6995
Mailing Address - Street 1:14892 SW 70 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193
Mailing Address - Country:US
Mailing Address - Phone:786-542-8179
Mailing Address - Fax:786-364-1871
Practice Address - Street 1:8181 NW 36 ST
Practice Address - Street 2:SUITE 17-A
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:786-542-8179
Practice Address - Fax:786-364-1871
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PM PSYCHOLOGICAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020580300Medicaid