MEDICARE: PENELOPE MARSHALL M.S.W.

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	1041C0700X	Clinical Social Worker	PSW 632	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSW632	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1003811878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PENELOPE MARSHALL M.S.W.

Provider Business Mailing Address
First Line	:	10080 SPYGLASS HILL LN
Second Line	:
City	:	FT MYERS
State	:	FL
Zip	:	33912-7971
Country	:	US
Telephone Number	:	239-275-5002
Fax Number	:

Provider Business Practice Location Address
First Line	:	9220 BONITA BEACH RD
Second Line	:	STE 227
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-4236
Country	:	US
Telephone Number	:	239-293-0122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/09/2007

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