Provider Demographics
NPI:1518921337
Name:SOUTHWEST FLORIDA ADDICTION SERVICE
Entity Type:Organization
Organization Name:SOUTHWEST FLORIDA ADDICTION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-332-6937
Mailing Address - Street 1:3763 EVANS AVENUE
Mailing Address - Street 2:
Mailing Address - City:FT. MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901
Mailing Address - Country:US
Mailing Address - Phone:239-332-6937
Mailing Address - Fax:239-332-0287
Practice Address - Street 1:3763 EVANS AVENUE
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901
Practice Address - Country:US
Practice Address - Phone:239-332-6937
Practice Address - Fax:239-332-0287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH1152251V00000X
251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0115162OtherAETNA MANAGEMENT
FL060613800Medicaid
IL189858OtherCOMPSYCH CORPORATION
IL189858OtherCOMPSYCH CORPORATION