Basic Information
| Provider Information | |||||||||
| NPI: | 1992314488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLPATH BEHAVIORAL AND PSYCHOLOGICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3720 19TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341176142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058156167 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3720 19TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341176142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058156167 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2020 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | CALDERON | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3058156167 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PY.D. | ||||||||
| NPICertificationDate: | 07/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.