Healthcare Provider Details

I. General information

NPI: 1659046852
Provider Name (Legal Business Name): BESPOKE PSYCHOTHERAPY SERVICES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17595 S TAMIAMI TRL STE 210
FORT MYERS FL
33908-4889
US

IV. Provider business mailing address

TODD A. BATTLES, LMHC 17595 SOUTH TAMIAMI TRAIL, SUITE 210
FORT MYERS FL
33908-4884
US

V. Phone/Fax

Practice location:
  • Phone: 239-310-2110
  • Fax: 239-310-2111
Mailing address:
  • Phone: 239-310-2110
  • Fax: 239-310-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TODD A. BATTLES
Title or Position: OWNER
Credential: LMHC
Phone: 239-310-2110