Healthcare Provider Details

I. General information

NPI: 1477386118
Provider Name (Legal Business Name): ANDREW DACOSTA PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 CREEKSIDE LN STE 4
FORT MYERS FL
33919-3353
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9220
  • Fax: 239-343-4240
Mailing address:
  • Phone: 393-439-2202
  • Fax: 239-343-4240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY12242
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY12242
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: