Healthcare Provider Details

I. General information

NPI: 1952967887
Provider Name (Legal Business Name): MAJOR IMPACT SUPPORT SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8875 HIDDEN RIVER PKWY
TAMPA FL
33637-1035
US

IV. Provider business mailing address

1960 VELASCO ST STE J2
FORT MYERS FL
33916-2761
US

V. Phone/Fax

Practice location:
  • Phone: 239-226-4357
  • Fax: 239-226-4352
Mailing address:
  • Phone: 239-822-8472
  • Fax: 239-226-4352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CLAYTON LAMBERT MAJOR SR.
Title or Position: CO-OWNER
Credential: MS
Phone: 239-822-8401