Healthcare Provider Details

I. General information

NPI: 1578203642
Provider Name (Legal Business Name): FAMILY INITIATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 SW 4TH ST UNIT 6
CAPE CORAL FL
33991-1922
US

IV. Provider business mailing address

734 SW 4TH ST UNIT 6
CAPE CORAL FL
33991-1922
US

V. Phone/Fax

Practice location:
  • Phone: 239-910-0712
  • Fax:
Mailing address:
  • Phone: 239-910-0712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CARTER THADDEUS DUMAS
Title or Position: REGISTERED BEHAVIOR TECHNICIAN
Credential:
Phone: 518-651-4408