=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952793069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CJS PSYCHOTHERAPY ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2015
-----------------------------------------------------
Last Update Date | 02/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11470 S CLEVELAND AVE
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-2323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-489-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1270 CLEBURNE DR
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33919-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-388-3422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | CHRISTOPHER JOHN SANTINI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 646-388-3422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW 12113
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------