Healthcare Provider Details

I. General information

NPI: 1417292954
Provider Name (Legal Business Name): KERRY M FICHTHORN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 EDUCATION AVE
PUNTA GORDA FL
33950-6222
US

IV. Provider business mailing address

1700 EDUCATION AVE
PUNTA GORDA FL
33950-6222
US

V. Phone/Fax

Practice location:
  • Phone: 941-639-8300
  • Fax: 941-347-6493
Mailing address:
  • Phone: 941-639-8300
  • Fax: 941-347-6493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11052
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: