Provider Demographics
NPI:1083865117
Name:BEHAVIORAL HEALTH SERVICES LCSW LLC
Entity Type:Organization
Organization Name:BEHAVIORAL HEALTH SERVICES LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FRATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:239-810-3998
Mailing Address - Street 1:16520 S TAMIAMI TRL
Mailing Address - Street 2:UNIT 138 PMB 187
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4569
Mailing Address - Country:US
Mailing Address - Phone:239-810-3998
Mailing Address - Fax:239-236-1215
Practice Address - Street 1:1415 PANTHER LN
Practice Address - Street 2:UNIT 142
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-7874
Practice Address - Country:US
Practice Address - Phone:239-810-3998
Practice Address - Fax:239-236-1215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW56021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBN268AMedicare UPIN