Basic Information
Provider Information
NPI: 1003142167
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KAMBURIAN
FirstName: MATHIEU
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PSY.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1150 HIBISCUS DR
Address2:  
City: PEMBROKE PINES
State: FL
PostalCode: 330254554
CountryCode: US
TelephoneNumber: 9549676300
FaxNumber: 9549676346
Practice Location
Address1: 1150 HIBISCUS DR
Address2:  
City: PEMBROKE PINES
State: FL
PostalCode: 330254554
CountryCode: US
TelephoneNumber: 9549676300
FaxNumber: 9549676346
Other Information
ProviderEnumerationDate: 10/26/2009
LastUpdateDate: 10/26/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700XPY7997FLY Behavioral Health & Social Service ProvidersPsychologistClinical

No ID Information.


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