Provider Demographics
NPI:1639896343
Name:CETOUTE, CLEEFF-THALY
Entity type:Individual
Prefix:
First Name:CLEEFF-THALY
Middle Name:
Last Name:CETOUTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 BROADWAY APT L8
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8035
Mailing Address - Country:US
Mailing Address - Phone:239-692-5998
Mailing Address - Fax:
Practice Address - Street 1:1490 NE PINE ISLAND RD STE 7E-F
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2135
Practice Address - Country:US
Practice Address - Phone:239-599-8733
Practice Address - Fax:239-599-8602
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-240983106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty