Healthcare Provider Details

I. General information

NPI: 1861515801
Provider Name (Legal Business Name): GULFSIDE HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6361 PRESIDENTIAL CT STE 105
FORT MYERS FL
33919-3583
US

IV. Provider business mailing address

6361 PRESIDENTIAL CT STE 105
FORT MYERS FL
33919-3583
US

V. Phone/Fax

Practice location:
  • Phone: 239-470-6810
  • Fax: 239-938-9912
Mailing address:
  • Phone: 239-470-6810
  • Fax: 239-938-9912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID E. WOOD
Title or Position: PRESIDENT
Credential:
Phone: 239-470-6810