Provider Demographics
NPI:1124123534
Name:FLORIDA MEDICAL PSYCHOLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:FLORIDA MEDICAL PSYCHOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:S
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-386-6800
Mailing Address - Street 1:12167 W. LINEBAUGH AVE.
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626
Mailing Address - Country:US
Mailing Address - Phone:813-386-6800
Mailing Address - Fax:813-891-1311
Practice Address - Street 1:12167 W. LINEBAUGH AVE.
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4615
Practice Address - Country:US
Practice Address - Phone:813-386-6800
Practice Address - Fax:813-891-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6274103G00000X
FLPY6420103T00000X
FLPY6377103TH0100X
FLPY6792103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty