Provider Demographics
NPI:1962855668
Name:SUNSHINE STATE COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:SUNSHINE STATE COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:MILENA
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-S
Authorized Official - Phone:239-495-7722
Mailing Address - Street 1:3575 BONITA BEACH RD STE 1
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4105
Mailing Address - Country:US
Mailing Address - Phone:239-495-7722
Mailing Address - Fax:
Practice Address - Street 1:3575 BONITA BEACH RD STE 1
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4105
Practice Address - Country:US
Practice Address - Phone:239-495-7722
Practice Address - Fax:239-443-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW126861041C0700X
FLSW133321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1163217Medicaid
FL014047700Medicaid
FL1117901Medicaid