Provider Demographics
NPI:1689286809
Name:CENTRAL FLORIDA PSYCHOTHERAPY SERVICES LLC
Entity Type:Organization
Organization Name:CENTRAL FLORIDA PSYCHOTHERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOMON
Authorized Official - Middle Name:
Authorized Official - Last Name:THEKKETHOTTIYIL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:330-416-3867
Mailing Address - Street 1:5302 S FLORIDA AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4910
Mailing Address - Country:US
Mailing Address - Phone:863-602-7001
Mailing Address - Fax:863-583-8585
Practice Address - Street 1:5302 S FLORIDA AVE STE 200
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-4922
Practice Address - Country:US
Practice Address - Phone:853-602-7001
Practice Address - Fax:863-583-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty