Provider Demographics
NPI:1457594954
Name:SOUTHWEST FLORIDA PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:SOUTHWEST FLORIDA PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:OLBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:941-204-0059
Mailing Address - Street 1:56 MANIZAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-4223
Mailing Address - Country:US
Mailing Address - Phone:941-204-0059
Mailing Address - Fax:
Practice Address - Street 1:56 MANIZAKS AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-4223
Practice Address - Country:US
Practice Address - Phone:941-204-0059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6434103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty