MEDICARE: TINA MARIE CORDELL

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	104100000X	Social Worker
2	222Q00000X	Developmental Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700903796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA MARIE CORDELL

Provider Business Mailing Address
First Line	:	8961 DANIELS CENTER DR STE 401
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-0314
Country	:	US
Telephone Number	:	239-433-6700
Fax Number	:	239-433-6703

Provider Business Practice Location Address
First Line	:	8961 DANIELS CENTER DR STE 401
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-0314
Country	:	US
Telephone Number	:	239-433-6700
Fax Number	:	239-433-6703

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

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	04/26/2012

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Directions to “ TINA MARIE CORDELL ” Practice Location

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