Healthcare Provider Details

I. General information

NPI: 1942516844
Provider Name (Legal Business Name): MIND AND BRAIN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10175 6 MILE CYPRESS PKWY STE 3
FORT MYERS FL
33966-6993
US

IV. Provider business mailing address

10175 6 MILE CYPRESS PKWY SUITE 3
FORT MYERS FL
33966-9663
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-6500
  • Fax:
Mailing address:
  • Phone: 239-768-6500
  • Fax: 239-768-6421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY7375
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY7375
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY7375
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPY7375
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY7375
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7375
License Number StateFL
# 7
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY7375
License Number StateFL

VIII. Authorized Official

Name: DR. MABEL LOPEZ
Title or Position: OWNER
Credential: PHD
Phone: 239-768-6500