Provider Demographics
NPI:1992448161
Name:THE ECOTHERAPY PLACE LLC
Entity type:Organization
Organization Name:THE ECOTHERAPY PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CRISTIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:239-895-6954
Mailing Address - Street 1:PO BOX 2037
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:FL
Mailing Address - Zip Code:33920-2037
Mailing Address - Country:US
Mailing Address - Phone:239-895-6954
Mailing Address - Fax:
Practice Address - Street 1:18320 PERSIMMON RIDGE RD
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:FL
Practice Address - Zip Code:33920-2037
Practice Address - Country:US
Practice Address - Phone:239-895-6954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-15
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111229900Medicaid
FL114247300Medicaid