MEDICARE: MS. DEBORAH MARY NORDSTROM LCSW

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	1026997	MA
2	1041C0700X	Clinical Social Worker	5608	TN
3	1041C0700X	Clinical Social Worker	12845	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P07591	OTHER	MA	BLUE CROSS BLUE SHIELD
2	1012450	OTHER	MA	FALLON COMM HP

General Provider Information

NPI Number	:	1295891984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEBORAH MARY NORDSTROM LCSW

Provider Business Mailing Address
First Line	:	111 WEST MAIN STREET
Second Line	:	SUITE 300
City	:	INVERNESS
State	:	FL
Zip	:	34450
Country	:	US
Telephone Number	:	352-476-3164
Fax Number	:	352-423-1351

Provider Business Practice Location Address
First Line	:	111 W MAIN ST STE 300
Second Line	:
City	:	INVERNESS
State	:	FL
Zip	:	34450-4807
Country	:	US
Telephone Number	:	352-476-3164
Fax Number	:

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	02/17/2024

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