Provider Demographics
NPI:1699152553
Name:SUNSHINE STATE COUNSELING CENTER LLC
Entity type:Organization
Organization Name:SUNSHINE STATE COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:MILENA
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-S
Authorized Official - Phone:239-495-7722
Mailing Address - Street 1:3575 BONITA BEACH RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4199
Mailing Address - Country:US
Mailing Address - Phone:239-495-7722
Mailing Address - Fax:239-443-4577
Practice Address - Street 1:13130 WESTLINKS TER STE 8
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8651
Practice Address - Country:US
Practice Address - Phone:239-495-7722
Practice Address - Fax:239-443-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW126861041C0700X, 1041C0700X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014047700Medicaid
FL124566645Medicaid
FL1003957382Medicaid