Provider Demographics
NPI:1912438375
Name:FORT LAUDERDALE PSYCHOLOGY PA
Entity Type:Organization
Organization Name:FORT LAUDERDALE PSYCHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLLE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:DELEO
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC PSYD
Authorized Official - Phone:954-260-8790
Mailing Address - Street 1:115 NE 3RD AVE
Mailing Address - Street 2:#305
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1291
Mailing Address - Country:US
Mailing Address - Phone:954-260-8790
Mailing Address - Fax:
Practice Address - Street 1:2755 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 225
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1637
Practice Address - Country:US
Practice Address - Phone:954-260-8790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH:10032101YM0800X
FLPY: 8799103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty