Provider Demographics
NPI:1750804563
Name:FLORES, NATHANIEL (PHD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:FLORES
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4522 W VILLAGE DR UNIT 1321
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-3429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8501 TEMPLE TERRACE HIGHWAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33637
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPY12040103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA$$$$$$$$$OtherNO INSURANCE