MEDICARE: STEPHEN LANCE WRIGHT PHD

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	103TC1900X	Counseling Psychologist	PY0004349	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	73636	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1043221096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN LANCE WRIGHT PHD

Provider Business Mailing Address
First Line	:	312 E GEORGIA ST
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32301-1250
Country	:	US
Telephone Number	:	850-222-3045
Fax Number	:	850-521-3422

Provider Business Practice Location Address
First Line	:	312 E GEORGIA ST
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32301-1250
Country	:	US
Telephone Number	:	850-222-3045
Fax Number	:	850-521-3422

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	08/15/2008

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