Healthcare Provider Details

I. General information

NPI: 1114440112
Provider Name (Legal Business Name): SOUTHWEST PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 07/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4706 CHIQUITA BLVD S STE 200
CAPE CORAL FL
33914-6324
US

IV. Provider business mailing address

4706 CHIQUITA BLVD S STE 200
CAPE CORAL FL
33914-6324
US

V. Phone/Fax

Practice location:
  • Phone: 239-834-9333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1290
License Number StateFL

VIII. Authorized Official

Name: MAREK R MOLDAWSKY JR.
Title or Position: OWNER
Credential: SCHOOL PSYCHOLOGIST
Phone: 239-834-9333