Provider Demographics
NPI:1760525539
Name:IMPACT FOR DEVELOPMENTAL EDUCATION, INC
Entity Type:Organization
Organization Name:IMPACT FOR DEVELOPMENTAL EDUCATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-334-6160
Mailing Address - Street 1:P.O. BOX 51319
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33994-1119
Mailing Address - Country:US
Mailing Address - Phone:239-334-6160
Mailing Address - Fax:239-334-1339
Practice Address - Street 1:1650 MEDICAL LANE SUITE 4
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1116
Practice Address - Country:US
Practice Address - Phone:239-334-6160
Practice Address - Fax:239-334-1339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251V00000XAgenciesVoluntary or Charitable
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811806000Medicaid