Healthcare Provider Details

I. General information

NPI: 1992448161
Provider Name (Legal Business Name): THE ECOTHERAPY PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18320 PERSIMMON RIDGE RD
ALVA FL
33920-2037
US

IV. Provider business mailing address

PO BOX 2037
ALVA FL
33920-2037
US

V. Phone/Fax

Practice location:
  • Phone: 239-895-6954
  • Fax:
Mailing address:
  • Phone: 239-895-6954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: CRISTIANE FERNANDES
Title or Position: CLINICIAN
Credential: LCSW
Phone: 239-895-6954