MEDICARE: JOHN PHILLIP JAMES PHD, LMHC MH15041

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	103TC1900X	Counseling Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MH15041	OTHER	FL	LICENSE NUMBER

General Provider Information

NPI Number	:	1770986903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN PHILLIP JAMES PHD, LMHC MH15041

Provider Business Mailing Address
First Line	:	4807 SUNSET CT
Second Line	:	APT 205
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-5040
Country	:	US
Telephone Number	:	845-300-4138
Fax Number	:	239-362-0710

Provider Business Practice Location Address
First Line	:	6313 CORPORATE CT STE 120
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-3509
Country	:	US
Telephone Number	:	845-300-4138
Fax Number	:	239-362-0710

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2014
Last Update Date	:	12/21/2021

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