MEDICARE: FORT MYERS PSYCHOLOGY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	74129	OTHER	FL	BCBS FLORIDA
2	NJ5TQ	OTHER	FL	BCBS-FL BLUE

General Provider Information

NPI Number	:	1003028119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT MYERS PSYCHOLOGY, PA

Provider Business Mailing Address
First Line	:	8430 BELLE MEADE DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-6009
Country	:	US
Telephone Number	:	239-826-7903
Fax Number	:	239-645-4777

Provider Business Practice Location Address
First Line	:	12791 WORLD PLAZA LN BLDG 89
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3989
Country	:	US
Telephone Number	:	239-829-5494
Fax Number	:	239-645-4777

Authorized Official
Title or Position	:	OFFICE BILLING ADMINISTRATOR
Name	:	BRENDA K SLUDER
Credential	:
Telephone Number	:	239-887-6004

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	12/16/2024

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