=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003028119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORT MYERS PSYCHOLOGY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12791 WORLD PLAZA LN BLDG 89
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-3989
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-829-5494
-----------------------------------------------------
Fax | 239-645-4777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8430 BELLE MEADE DR
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908-6009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-826-7903
-----------------------------------------------------
Fax | 239-645-4777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE BILLING ADMINISTRATOR
-----------------------------------------------------
Name | BRENDA K SLUDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-887-6004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------