MEDICARE: DR. MARISA BERMUDEZ PSYD

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	103T00000X	Psychologist	PY10455	FL

General Provider Information

NPI Number	:	1013460823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARISA BERMUDEZ PSYD

Provider Business Mailing Address
First Line	:	12499 BRANTLEY COMMONS CT STE 101
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-5694
Country	:	US
Telephone Number	:	239-278-3443
Fax Number	:	239-278-3550

Provider Business Practice Location Address
First Line	:	12499 BRANTLEY COMMONS CT STE 101
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-5694
Country	:	US
Telephone Number	:	239-278-3443
Fax Number	:	239-278-3550

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

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	07/12/2019

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