MEDICARE: KENT ISLAND PSYCHOLOGICAL SERVICES 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	103T00000X	Psychologist	PY6631	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11804019	OTHER	FL	CAQH
2	73032	OTHER	FL	BC/BS

General Provider Information

NPI Number	:	1518020957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENT ISLAND PSYCHOLOGICAL SERVICES INC

Provider Business Mailing Address
First Line	:	PO BOX 4466
Second Line	:
City	:	N FORT MYERS
State	:	FL
Zip	:	33918-4466
Country	:	US
Telephone Number	:	239-887-8999
Fax Number	:

Provider Business Practice Location Address
First Line	:	13180 N CLEVELAND AVE STE 312
Second Line	:
City	:	N FORT MYERS
State	:	FL
Zip	:	33903-6231
Country	:	US
Telephone Number	:	239-887-8999
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RONALD GERALD DALRYMPLE
Credential	:	PH D
Telephone Number	:	239-887-8999

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	04/24/2025

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