Healthcare Provider Details

I. General information

NPI: 1730768797
Provider Name (Legal Business Name): LUCKY BEHAVIOR SERVICES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 05/12/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 DEL PRADO BLVD. UNIT 125
CAPE CORAL FL
33904-7283
US

IV. Provider business mailing address

2804 DEL PRADO BLVD S STE 209-2
CAPE CORAL FL
33904-7283
US

V. Phone/Fax

Practice location:
  • Phone: 239-298-6868
  • Fax:
Mailing address:
  • Phone: 239-298-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARELIA MARIA FERNANDEZ
Title or Position: PRESIDENT
Credential:
Phone: 239-298-6868