Healthcare Provider Details

I. General information

NPI: 1104540038
Provider Name (Legal Business Name): SYCAMORE SHADE COUNSELING AND CONSULTATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 SUMMERLIN COMMONS WAY STE 1002
FORT MYERS FL
33907-2162
US

IV. Provider business mailing address

5290 SUMMERLIN COMMONS WAY STE 1002
FORT MYERS FL
33907-2162
US

V. Phone/Fax

Practice location:
  • Phone: 321-300-6171
  • Fax:
Mailing address:
  • Phone: 321-300-6171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANA MARI ALLEN
Title or Position: MENTAL HEALTH COUNSELOR
Credential: LMHC
Phone: 321-300-6171