Healthcare Provider Details

I. General information

NPI: 1104639095
Provider Name (Legal Business Name): JESSICA TANDY LYREK LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 NEAL RD
FORT MYERS FL
33905-6828
US

IV. Provider business mailing address

6440 NEAL RD
FORT MYERS FL
33905-6828
US

V. Phone/Fax

Practice location:
  • Phone: 612-267-5107
  • Fax:
Mailing address:
  • Phone: 612-267-5107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT5136
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: