Provider Demographics
NPI:1730539941
Name:FLORIDA PSYCHOTHERAPY SERVICES LLC
Entity type:Organization
Organization Name:FLORIDA PSYCHOTHERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOMON
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:THEKKETHOTTIYIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-424-8423
Mailing Address - Street 1:3835 MISTY LANDING DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-4802
Mailing Address - Country:US
Mailing Address - Phone:727-424-8423
Mailing Address - Fax:
Practice Address - Street 1:106 W WINDHORST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-2455
Practice Address - Country:US
Practice Address - Phone:813-373-9531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW108061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty