Healthcare Provider Details

I. General information

NPI: 1548601990
Provider Name (Legal Business Name): MARY ELIZABETH ANN DICKOUT B.A.,CPRP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3763 EVANS AVE
FORT MYERS FL
33901-9302
US

IV. Provider business mailing address

3763 EVANS AVE
FORT MYERS FL
33901-9302
US

V. Phone/Fax

Practice location:
  • Phone: 239-332-6937
  • Fax: 239-332-6985
Mailing address:
  • Phone: 239-931-9827
  • Fax: 239-332-6985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number171637
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: