1215110820 NPI number — FAMILY THERAPY SERVICES, INC.

Table of content: JESSIE LYNN ROBERTS DPT (NPI 1215041363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215110820 NPI number — FAMILY THERAPY SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY THERAPY SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215110820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1740 SW ST LUCIE BLVD
Provider Second Line Business Mailing Address:
SUITE #101
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34986-2504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-812-8960
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10801 SW TRADITION SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34987-1934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-345-3933
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FETTROW
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/THERAPIST
Authorized Official Telephone Number:
772-812-8960

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  MT 2260 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)