MEDICARE: ISIS CANCEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	CBHCM.0100471	FL

General Provider Information

NPI Number	:	1407230998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISIS CANCEL

Provider Business Mailing Address
First Line	:	4621 EGG HARBOR DR
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34746-2011
Country	:	US
Telephone Number	:	407-910-3862
Fax Number	:

Provider Business Practice Location Address
First Line	:	4621 EGG HARBOR DR
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34746-2011
Country	:	US
Telephone Number	:	407-910-3862
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2015
Last Update Date	:	06/21/2024

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