Provider Demographics
NPI:1215262977
Name:MID STATE MENTAL HEALTH ASSESSMENT INC
Entity type:Organization
Organization Name:MID STATE MENTAL HEALTH ASSESSMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:239-352-4004
Mailing Address - Street 1:5819 PLYMOUTH PL
Mailing Address - Street 2:
Mailing Address - City:AVE MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34142-9586
Mailing Address - Country:US
Mailing Address - Phone:239-352-4004
Mailing Address - Fax:
Practice Address - Street 1:7052 ANNUNCIATION CIRCLE
Practice Address - Street 2:SUITE 329
Practice Address - City:AVE MARIA
Practice Address - State:FL
Practice Address - Zip Code:34142-0000
Practice Address - Country:US
Practice Address - Phone:239-352-4004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8461103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty