Provider Demographics
NPI:1518020957
Name:KENT ISLAND PSYCHOLOGICAL SERVICES INC
Entity Type:Organization
Organization Name:KENT ISLAND PSYCHOLOGICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:DALRYMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:239-997-0700
Mailing Address - Street 1:PO BOX 4466
Mailing Address - Street 2:
Mailing Address - City:N FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33918-4466
Mailing Address - Country:US
Mailing Address - Phone:239-997-0700
Mailing Address - Fax:239-997-0456
Practice Address - Street 1:13180 N CLEVELAND AVE
Practice Address - Street 2:SUITE 232
Practice Address - City:N FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-6200
Practice Address - Country:US
Practice Address - Phone:239-997-0700
Practice Address - Fax:239-997-0456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6631103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73032OtherBC/BS
FL11804019OtherCAQH
FL11804019OtherCAQH
FL73032ZMedicare PIN