=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205412236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESIREE ALDAG CBHCMS, CAP, CTP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2021
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4902 EISENHOWER BLVD STE 315
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33634-6344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-786-7681
-----------------------------------------------------
Fax | 813-283-9110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1277 LEGATTO LOOP
-----------------------------------------------------
City | DUNDEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33838-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-508-4512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | CBHCMS.0102754
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------