Healthcare Provider Details

I. General information

NPI: 1548864556
Provider Name (Legal Business Name): ALL FLORIDA ABA CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 01/28/2021
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5240 BANK ST STE 14
FORT MYERS FL
33907-2110
US

IV. Provider business mailing address

5540 BANK ST SUIT 14
FORT MYERS FL
33907
US

V. Phone/Fax

Practice location:
  • Phone: 786-269-8757
  • Fax:
Mailing address:
  • Phone: 786-269-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: REYDEL LOPEZ MENDEZ
Title or Position: PRESIDENT
Credential:
Phone: 786-269-8757