=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003399676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIREILLE TAIME MSW LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2018
-----------------------------------------------------
Last Update Date | 09/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 PONDELLA RD STE 9
-----------------------------------------------------
City | NORTH FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33903-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-652-0260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4112 12TH ST W
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33971-5021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-839-9399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 15686
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------