Provider Demographics
NPI:1871775445
Name:MAITLAND PSYCHOLOGY PA
Entity type:Organization
Organization Name:MAITLAND PSYCHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANO
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LELI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:407-628-5354
Mailing Address - Street 1:PO BOX 947617
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32794-7617
Mailing Address - Country:US
Mailing Address - Phone:407-628-5354
Mailing Address - Fax:407-628-0254
Practice Address - Street 1:500 N. MAITLAND AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751
Practice Address - Country:US
Practice Address - Phone:407-628-5354
Practice Address - Fax:407-628-0254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3919103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K4265AMedicare PIN
FLK4265Medicare PIN