MEDICARE: MRS. CAROL G FORTUNE LICSW

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	1041C0700X	Clinical Social Worker	SW8072	FL
2	1041C0700X	Clinical Social Worker	103065	MA

General Provider Information

NPI Number	:	1578673083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL G FORTUNE LICSW

Provider Business Mailing Address
First Line	:	1522 GOLDEN RIDGE DR
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32162-6765
Country	:	US
Telephone Number	:	352-638-2264
Fax Number	:	352-259-4050

Provider Business Practice Location Address
First Line	:	1522 GOLDEN RIDGE DR
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32162-6765
Country	:	US
Telephone Number	:	352-638-2264
Fax Number	:	352-259-4050

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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