Healthcare Provider Details

I. General information

NPI: 1689903650
Provider Name (Legal Business Name): SOUTHWEST FLORIDA ASSOCIATES IN MENTAL HEALTH AND ADDICTIONS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12657 NEW BRITTANY BLVD SUITE 12
FORT MEYERS FL
33907-3631
US

IV. Provider business mailing address

12657 NEW BRITTANY BLVD SUITE 12
FORT MEYERS FL
33907-3631
US

V. Phone/Fax

Practice location:
  • Phone: 239-940-1804
  • Fax: 239-275-3964
Mailing address:
  • Phone: 239-940-1804
  • Fax: 239-275-3964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPY0003960
License Number StateFL

VIII. Authorized Official

Name: DR. NICHOLAS CHARLES ANTHONY
Title or Position: PRESIDENT
Credential: PHD
Phone: 239-940-1804