Basic Information
| Provider Information | |||||||||
| NPI: | 1063964484 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DNA COMPREHENSIVE THERAPY SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELITE DNA THERAPY SERVICES, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4310 METRO PKWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
| FaxNumber: | 2395612933 | ||||||||
| Practice Location | |||||||||
| Address1: | 6360 TECHSTER BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339664805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
| FaxNumber: | 2395612933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2016 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | DOSORETZ | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2392368784 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.