Provider Demographics
NPI:1831381722
Name:NUSSBAUMER, JOSEPH WM JR (PHD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WM
Last Name:NUSSBAUMER
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-2731
Mailing Address - Country:US
Mailing Address - Phone:352-429-5600
Mailing Address - Fax:352-429-1206
Practice Address - Street 1:627 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-2731
Practice Address - Country:US
Practice Address - Phone:352-429-5600
Practice Address - Fax:352-429-1206
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCPY0003010493-FACCT103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
034015OtherVALUE OPTIONS