Provider Demographics
NPI:1184112906
Name:FENIX BEHAVIOR THERAPY CO.
Entity type:Organization
Organization Name:FENIX BEHAVIOR THERAPY CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUCEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TEJEDA
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:239-628-6999
Mailing Address - Street 1:6660 ESTERO BLVD UNIT B404
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33931-4567
Mailing Address - Country:US
Mailing Address - Phone:239-628-6999
Mailing Address - Fax:
Practice Address - Street 1:1705 COLONIAL BLVD STE B4
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1141
Practice Address - Country:US
Practice Address - Phone:239-628-6999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty