NPIMap

Organization Active NPI

Neurogenesis Center of Florida, PLLC

  • Clinical Psychologist
  • Maitland, FL
National Provider Identifier
1922474907
Registry record updated Apr 24, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
PY9333 Issued in FL
Legal business name
NEUROGENESIS CENTER OF FLORIDA, PLLC
Practice address
253 N Orlando Ave Ste 202
Maitland, FL 32751-5521
Phone
(407) 790-4101
Fax
(407) 277-4400
NPI assigned
Aug 13, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 24, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amber L FasulaNPI 1730364472
Title
Owner
Phone
(407) 790-4101

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193400000X SINGLE SPECIALTY GROUP 103TC0700X PY9333 FL Primary

Addresses

Primary practice location

253 N Orlando Ave Ste 202
Maitland, FL 32751-5521

Mailing address

253 N Orlando Ave Ste 202
Maitland, FL 32751-5521
Phone (407) 790-4101

Other names 1

  • Amber Fasula, Psy.D. Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190912002470 FL Part B Supplier - Clinic/Group Practice 9739420365 Receives reassigned benefits from 6 practitioners
Practice locations: Maitland, FL

National Provider Directory

National Provider Directory

Locations

253 N Orlando Ave
Ste 202
Maitland, FL 32751
Phone (407) 427-1855

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1439424000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1619222400000",
    "number": "1922474907",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "253 N ORLANDO AVE STE 202",
            "city": "MAITLAND",
            "state": "FL",
            "postal_code": "327515521",
            "telephone_number": "407-790-4101",
            "fax_number": "407-277-4400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "253 N ORLANDO AVE STE 202",
            "city": "MAITLAND",
            "state": "FL",
            "postal_code": "327515521",
            "telephone_number": "407-790-4101",
            "fax_number": "407-277-4400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NEUROGENESIS CENTER OF FLORIDA, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-08-13",
        "last_updated": "2021-04-24",
        "certification_date": "2021-04-24",
        "status": "A",
        "authorized_official_last_name": "FASULA",
        "authorized_official_first_name": "AMBER",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "407-790-4101"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical",
            "state": "FL",
            "license": "PY9333",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Amber Fasula, Psy.D.",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Amber Fasula, Psy.D.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Maitland, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.