Healthcare Provider Details

I. General information

NPI: 1497649032
Provider Name (Legal Business Name): THE GOLDEN AGE MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 NE PINE ISLAND RD BLDG 6
CAPE CORAL FL
33909-2135
US

IV. Provider business mailing address

1490 NE PINE ISLAND RD BLDG 6
CAPE CORAL FL
33909-2135
US

V. Phone/Fax

Practice location:
  • Phone: 239-203-1248
  • Fax: 239-510-2292
Mailing address:
  • Phone: 239-203-1248
  • Fax: 239-510-2292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ROSSANA CEPERO
Title or Position: OWNER
Credential:
Phone: 239-203-1248