Basic Information
| Provider Information | |||||||||
| NPI: | 1225400294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DNA COMPREHENSIVE THERAPY SERVICES, LLC | ||||||||
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| OtherOrganizationName: | ELITE DNA THERAPY SERVICES, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6360 TECHSTER BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339664805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
| FaxNumber: | 2395612933 | ||||||||
| Practice Location | |||||||||
| Address1: | 3191 HARBOR BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339526755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418331750 | ||||||||
| FaxNumber: | 2395612933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2015 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOSORETZ | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | FOUNDER AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 2392232751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.