Provider Demographics
NPI:1720114762
Name:FEDERER, DENISE P (PHD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:P
Last Name:FEDERER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3641 W KENNEDY BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2851
Mailing Address - Country:US
Mailing Address - Phone:813-876-7191
Mailing Address - Fax:813-876-9008
Practice Address - Street 1:3641 W KENNEDY BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2851
Practice Address - Country:US
Practice Address - Phone:813-876-7191
Practice Address - Fax:813-876-9008
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3573103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75756Medicare ID - Type Unspecified