Provider Demographics
NPI:1407211535
Name:MAJOR IMPACT, INC.
Entity Type:Organization
Organization Name:MAJOR IMPACT, INC.
Other - Org Name:MAJOR IMPACT, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:LAMBERT
Authorized Official - Last Name:MAJOR
Authorized Official - Suffix:SR
Authorized Official - Credentials:MS
Authorized Official - Phone:239-226-4357
Mailing Address - Street 1:1960 VELASCO ST
Mailing Address - Street 2:SUITE J-2
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2761
Mailing Address - Country:US
Mailing Address - Phone:239-226-4357
Mailing Address - Fax:239-226-4352
Practice Address - Street 1:1960 VELASCO ST
Practice Address - Street 2:SUITE J-2
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-2761
Practice Address - Country:US
Practice Address - Phone:239-226-4357
Practice Address - Fax:239-226-4352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2036AD2405-01101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003799000Medicaid