Healthcare Provider Details

I. General information

NPI: 1386220432
Provider Name (Legal Business Name): SOUTHWEST FLORIDA BEHAVIORAL HEALTH L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SW 31ST ST
CAPE CORAL FL
33914-4555
US

IV. Provider business mailing address

124 SW 31ST ST
CAPE CORAL FL
33914-4555
US

V. Phone/Fax

Practice location:
  • Phone: 239-738-6365
  • Fax:
Mailing address:
  • Phone: 239-738-6365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: CARLOS MANUEL CHICA
Title or Position: OWNER
Credential: BCBA
Phone: 239-738-6365