MEDICARE: IMPACT FOR DEVELOPMENTAL EDUCATION, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386368801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT FOR DEVELOPMENTAL EDUCATION, INC

Provider Business Mailing Address
First Line	:	1650 MEDICAL LN STE 4
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1116
Country	:	US
Telephone Number	:	239-628-1061
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 MEDICAL LANE SUITE 4
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1116
Country	:	US
Telephone Number	:	239-334-6160
Fax Number	:	239-334-1339

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MAXINE GIBBS
Credential	:
Telephone Number	:	239-628-1061

Provider Enumeration Date	:	09/28/2022
Last Update Date	:	05/28/2026

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