=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689286809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL FLORIDA PSYCHOTHERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2020
-----------------------------------------------------
Last Update Date | 08/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5302 S FLORIDA AVE STE 200
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-4922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 853-602-7001
-----------------------------------------------------
Fax | 863-583-8585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5302 S FLORIDA AVE STE 203
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-4910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-602-7001
-----------------------------------------------------
Fax | 863-583-8585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOMON THEKKETHOTTIYIL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 330-416-3867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------