Basic Information
| Provider Information | |||||||||
| NPI: | 1750673950 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NURSING HOME PSYCHOLOGICAL SERVICES OF FL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 85 WHISPERWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704581136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857818565 | ||||||||
| FaxNumber: | 9857815395 | ||||||||
| Practice Location | |||||||||
| Address1: | 3795 SCENIC HIGHWAY 98 UNIT 6B | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325415772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857818565 | ||||||||
| FaxNumber: | 9857818565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2011 | ||||||||
| LastUpdateDate: | 05/05/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HESSON | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2568254135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSYD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.