Healthcare Provider Details

I. General information

NPI: 1639461312
Provider Name (Legal Business Name): FAMILY PRESERVATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 MARAVILLA LN
FORT MYERS FL
33901-7221
US

IV. Provider business mailing address

2180 MARAVILLA LN
FORT MYERS FL
33901-7221
US

V. Phone/Fax

Practice location:
  • Phone: 239-332-8009
  • Fax: 239-332-4977
Mailing address:
  • Phone: 239-332-8009
  • Fax: 239-332-4977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1063528560
License Number StateFL

VIII. Authorized Official

Name: MR. GERARD V SPRAGUE
Title or Position: CLINICAL SUPERVISOR
Credential: LMHC
Phone: 239-332-8009