Basic Information
Provider Information | |||||||||
NPI: | 1043450067 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ENGELMAN | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1081 | ||||||||
Address2: |   | ||||||||
City: | OLDSMAR | ||||||||
State: | FL | ||||||||
PostalCode: | 346771081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7274921253 | ||||||||
FaxNumber: | 8138546188 | ||||||||
Practice Location | |||||||||
Address1: | 302 VISTA LAKE CIR | ||||||||
Address2: |   | ||||||||
City: | PONTE VEDRA | ||||||||
State: | FL | ||||||||
PostalCode: | 320810080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7274921253 | ||||||||
FaxNumber: | 7273503255 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2009 | ||||||||
LastUpdateDate: | 08/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-03-1275 | FL | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 017523500 | 05 | FL |   | MEDICAID |