Healthcare Provider Details

I. General information

NPI: 1417789942
Provider Name (Legal Business Name): MACUS LORMIL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8570 GRANITE CT STE 101
FORT MYERS FL
33908-4240
US

IV. Provider business mailing address

3763 EVANS AVE
FORT MYERS FL
33901-9302
US

V. Phone/Fax

Practice location:
  • Phone: 833-769-3524
  • Fax:
Mailing address:
  • Phone: 239-308-1289
  • Fax: 239-332-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW23306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: