Provider Demographics
NPI:1093574592
Name:M TAVERAS PSYD & COMPANY PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:M TAVERAS PSYD & COMPANY PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:CHRISTY
Authorized Official - Last Name:TAVERAS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:347-251-2090
Mailing Address - Street 1:13241 BARTRAM PARK BLVD UNIT 805
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5216
Mailing Address - Country:US
Mailing Address - Phone:904-373-8427
Mailing Address - Fax:
Practice Address - Street 1:1629 RACE TRACK RD STE 102
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-6299
Practice Address - Country:US
Practice Address - Phone:904-204-2433
Practice Address - Fax:904-675-0987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-18
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty