1306947809 NPI number — DR. KARA MATILE HENDRY PSYD

Table of content: DR. KARA MATILE HENDRY PSYD (NPI 1306947809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306947809 NPI number — DR. KARA MATILE HENDRY PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRY
Provider First Name:
KARA
Provider Middle Name:
MATILE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306947809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 47918
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-322-6123
Provider Business Mailing Address Fax Number:
727-322-6143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5348 1ST AVE N
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33710-8106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-322-6123
Provider Business Practice Location Address Fax Number:
727-322-6143
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY6690 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 54889 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 55011000 . This is a "MAGELLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 687018079 . This is a "BRAIN AND SPINAL CORD INJ" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: FL2056 . This is a "BRADMAN NETWORK" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3402278 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2179838 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6870180701 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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