=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922246107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA M URKOVICH PHD.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2009
-----------------------------------------------------
Last Update Date | 01/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15670 MCGREGOR BLVD STE 102
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-849-1592
-----------------------------------------------------
Fax | 239-415-3641
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15670 MCGREGOR BLVD STE 102
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-849-1592
-----------------------------------------------------
Fax | 239-415-3641
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH5395
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------