Basic Information
| Provider Information | |||||||||
| NPI: | 1619641982 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DNA COMPREHENSIVE THERAPY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4310 METRO PKWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392368784 | ||||||||
| FaxNumber: | 2397902624 | ||||||||
| Practice Location | |||||||||
| Address1: | 2625 EXECUTIVE PARK DR STE 5 | ||||||||
| Address2: | |||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333313634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416940211 | ||||||||
| FaxNumber: | 9546940212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | CURTIS | ||||||||
| AuthorizedOfficialFirstName: | JASMINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2392368784 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DNA COMPREHENSIVE THERAPY SERVICES, LLC | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.