Provider Demographics
NPI:1982978193
Name:GUY L TEWKSBURY, PH.D. PA
Entity type:Organization
Organization Name:GUY L TEWKSBURY, PH.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TEWKSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD PA
Authorized Official - Phone:727-375-5924
Mailing Address - Street 1:50 8TH AVE SW
Mailing Address - Street 2:# 2006
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3638
Mailing Address - Country:US
Mailing Address - Phone:727-375-5924
Mailing Address - Fax:
Practice Address - Street 1:11590 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-3204
Practice Address - Country:US
Practice Address - Phone:727-375-5924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4179103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73810Medicare PIN