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General NPI Number Information
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NPI Number | 1316567472
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Entity Type | Organization
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Legal Business Name | RADICALLY OPEN DBT TAMPA
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Dates
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Enumeration Date | 04/19/2020
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Last Update Date | 12/28/2024
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Provider Practice Location Address
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Address Line | 1341 WINDSOR WAY
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City | LUTZ
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State | FL
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Zip | 33559-6742
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Country | US
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Telephone | 813-602-2312
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Fax | 813-336-8506
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Provider Business Mailing Address
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Address Line | 2751 EAST COUNTY LINE RD PMB #300
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City | LUTZ
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State | FL
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Zip | 33559-3439
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Country | US
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Telephone | 813-602-2312
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Fax | 813-302-1173
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Authorized Official
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Title or Position | OWNER
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Name | HEIDI A ISON-LUSTBERG
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Credential | LCSW
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Telephone | 813-602-2312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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