Provider Demographics
NPI:1427463850
Name:WESLEY PETER BLITCHINGTON, PH.D.
Entity type:Organization
Organization Name:WESLEY PETER BLITCHINGTON, PH.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:BLITCHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:407-774-0557
Mailing Address - Street 1:2909 W STATE ROAD 434 STE 111
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4459
Mailing Address - Country:US
Mailing Address - Phone:407-774-0557
Mailing Address - Fax:407-774-9329
Practice Address - Street 1:2909 W STATE ROAD 434 STE 111
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4459
Practice Address - Country:US
Practice Address - Phone:407-774-0557
Practice Address - Fax:407-774-9329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3223103T00000X, 103TB0200X, 103TC0700X, 103TC1900X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053110OtherVALUE OPTIONS
FL75237OtherFLORIDA BLUE
FL75237OtherMEDICARE
FL6126818OtherUNITED BEHAVIORAL HEALTH
FL63893OtherCIGNA
FL75237OtherMEDICARE P10