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NPI Code Detail

MEDICARE: FLORIDA PSYCHOTHERAPY SERVICES LLC

MEDICARE: FLORIDA PSYCHOTHERAPY SERVICES LLC
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
11041C0700XClinical Social WorkerSW10806FL

General Provider Information

NPI Number : 1730539941
Entity Type Code : Organization
Provider Name (Legal Business Name) : FLORIDA PSYCHOTHERAPY SERVICES LLC
Provider Business Mailing Address
First Line : 3835 MISTY LANDING DR
Second Line :
City : VALRICO
State : FL
Zip : 33594-4802
Country : US
Telephone Number : 727-424-8423
Fax Number :
Provider Business Practice Location Address
First Line : 106 W WINDHORST RD
Second Line :
City : BRANDON
State : FL
Zip : 33510-2455
Country : US
Telephone Number : 813-373-9531
Fax Number :
Authorized Official
Title or Position : MANAGER
Name : JOMON JOHN THEKKETHOTTIYIL
Credential :
Telephone Number : 727-424-8423
Provider Enumeration Date : 06/18/2016
Last Update Date : 06/18/2016

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