Provider Demographics
NPI:1386086726
Name:DEEP RIVER PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:DEEP RIVER PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:H
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:941-721-6325
Mailing Address - Street 1:323 10TH AVE W
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-5047
Mailing Address - Country:US
Mailing Address - Phone:941-721-6325
Mailing Address - Fax:941-723-6741
Practice Address - Street 1:323 10TH AVE W
Practice Address - Street 2:SUITE 302
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-5047
Practice Address - Country:US
Practice Address - Phone:941-721-6325
Practice Address - Fax:941-723-6741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5572261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54125Medicare UPIN