Basic Information
| Provider Information | |||||||||
| NPI: | 1376773614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC PSYCHOLOGY ASSOCIATES PL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIC PSYCHOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19022 NE 29TH AVE | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331802823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059361002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19022 NE 29TH AVE | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331802823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059361002 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 07/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | CARELLA | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3059361002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.