Healthcare Provider Details

I. General information

NPI: 1366971673
Provider Name (Legal Business Name): STEPHANIE MARIE ROQUE MIDONECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 GOODLETTE FRANK RD
NAPLES FL
34102-5661
US

IV. Provider business mailing address

501 GOODLETTE FRANK RD
NAPLES FL
34102-5661
US

V. Phone/Fax

Practice location:
  • Phone: 239-289-9796
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: