Healthcare Provider Details

I. General information

NPI: 1386553618
Provider Name (Legal Business Name): ELIZABETH DE LA CARIDAD LICEA FORNARIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3722 CENTRAL AVE STE 6
FORT MYERS FL
33901-8247
US

IV. Provider business mailing address

1010 RIDGEWAY DR
NORTH FORT MYERS FL
33903-4244
US

V. Phone/Fax

Practice location:
  • Phone: 239-848-5560
  • Fax: 855-521-0661
Mailing address:
  • Phone: 239-309-3367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: