Provider Demographics
NPI:1811178387
Name:RIVERSIDE PSYCHOLOGICAL GROUP
Entity type:Organization
Organization Name:RIVERSIDE PSYCHOLOGICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CIMINO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:954-755-4778
Mailing Address - Street 1:1801 UNIVERSITY DRIVE
Mailing Address - Street 2:PENTHOUSE SUITE A
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071
Mailing Address - Country:US
Mailing Address - Phone:954-755-4778
Mailing Address - Fax:954-755-0240
Practice Address - Street 1:1801 UNIVERSITY DRIVE
Practice Address - Street 2:PENTHOUSE A
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071
Practice Address - Country:US
Practice Address - Phone:954-755-4778
Practice Address - Fax:954-755-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4734103TC0700X
FLPY0004734103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73993SMedicare UPIN
FL40147Medicare PIN