Provider Demographics
NPI:1457002164
Name:SOUTHWEST FLORIDA SPORTS COUNSELING LLC
Entity Type:Organization
Organization Name:SOUTHWEST FLORIDA SPORTS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:941-677-8002
Mailing Address - Street 1:621 CAPE CORAL PKWY E STE 19C
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8548
Mailing Address - Country:US
Mailing Address - Phone:941-677-8002
Mailing Address - Fax:
Practice Address - Street 1:621 CAPE CORAL PKWY E STE 19C
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8548
Practice Address - Country:US
Practice Address - Phone:941-677-8002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty