Healthcare Provider Details

I. General information

NPI: 1144877424
Provider Name (Legal Business Name): GULFSHORE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 11/12/2023
Certification Date: 11/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 MATTHEW DR
FORT MYERS FL
33907-1734
US

IV. Provider business mailing address

1555 MATTHEW DR
FORT MYERS FL
33907-1734
US

V. Phone/Fax

Practice location:
  • Phone: 239-533-9860
  • Fax:
Mailing address:
  • Phone: 239-533-9860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMANTHA DENBOER
Title or Position: OWNER, LICENSED PSYCHOLOGIST
Credential:
Phone: 239-533-9860