Provider Demographics
NPI:1528127081
Name:PSYCHOLOGICAL AND NEUROBEHAVIORAL SERVICES P A
Entity type:Organization
Organization Name:PSYCHOLOGICAL AND NEUROBEHAVIORAL SERVICES P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:HENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:863-701-9202
Mailing Address - Street 1:4720 CLEVELAND HEIGHTS BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2243
Mailing Address - Country:US
Mailing Address - Phone:863-701-9202
Mailing Address - Fax:863-701-9262
Practice Address - Street 1:4720 CLEVELAND HEIGHTS BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2243
Practice Address - Country:US
Practice Address - Phone:863-701-9202
Practice Address - Fax:863-701-9262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2915Medicare ID - Type UnspecifiedMEDICARE PROVIDER
FLK2915Medicare PIN