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General NPI Number Information
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NPI Number | 1679168371
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Entity Type | Individual
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Provider Name | BETHANY M MORAN LCSW
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Gender | Female
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Dates
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Enumeration Date | 03/04/2021
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Last Update Date | 08/19/2021
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Provider Practice Location Address
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Address Line | 17595 S TAMIAMI TRL STE 225
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City | FORT MYERS
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State | FL
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Zip | 33908-4819
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Country | US
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Telephone | 239-898-0094
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Fax | 239-362-2466
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Provider Business Mailing Address
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Address Line | 17595 S TAMIAMI TRL STE 225
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City | FORT MYERS
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State | FL
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Zip | 33908-4819
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Country | US
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Telephone | 239-898-0094
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Fax | 239-362-2466
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW15348
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License Number State | FL
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