=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023410396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLB, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2014
-----------------------------------------------------
Last Update Date | 01/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5020 TAMIAMI TRL N SUITE 202
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34103-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-682-3251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5020 TAMIAMI TRL N SUITE 202
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34103-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-682-3251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | SUSAN BRENNER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 239-682-3251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW12189
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------