MEDICARE: DR. STEPHEN FORTSON ED.D. PCC-S

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	101YP2500X	Professional Counselor	E-1935	OH

General Provider Information

NPI Number	:	1285081307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN FORTSON ED.D. PCC-S

Provider Business Mailing Address
First Line	:	51 IRONGATE PARK DR
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4616
Country	:	US
Telephone Number	:	937-439-4220
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 IRONGATE PARK DR
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4616
Country	:	US
Telephone Number	:	937-439-4220
Fax Number	:

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

Provider Enumeration Date	:	05/18/2016
Last Update Date	:	05/18/2016

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