Provider Demographics
NPI:1063743896
Name:SUNCOAST PEDIATRIC EPILEPSY AND NEUROPSYCHOLOGY SPECIALISTS
Entity type:Organization
Organization Name:SUNCOAST PEDIATRIC EPILEPSY AND NEUROPSYCHOLOGY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:813-633-6000
Mailing Address - Street 1:833 CYPRESS VILLAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6822
Mailing Address - Country:US
Mailing Address - Phone:813-633-6000
Mailing Address - Fax:
Practice Address - Street 1:833 CYPRESS VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33573-6822
Practice Address - Country:US
Practice Address - Phone:813-633-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5685103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBH036ZOtherMEDICARE