Basic Information
| Provider Information | |||||||||
| NPI: | 1730241209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENSACOLA PSYCHOLOGICAL CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 229 S BAYLEN ST | ||||||||
| Address2: | STE 2 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325025852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504331656 | ||||||||
| FaxNumber: | 8504331996 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 W GARDEN ST | ||||||||
| Address2: | STE 370 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325025641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504331656 | ||||||||
| FaxNumber: | 8504331996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | GROOM | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8504331656 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.