Provider Demographics
NPI:1417292954
Name:FICHTHORN, KERRY M (LCSW)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:M
Last Name:FICHTHORN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 EDUCATION AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-6222
Mailing Address - Country:US
Mailing Address - Phone:941-639-8300
Mailing Address - Fax:941-347-6493
Practice Address - Street 1:1700 EDUCATION AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-6222
Practice Address - Country:US
Practice Address - Phone:941-639-8300
Practice Address - Fax:941-347-6493
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW110521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007717300Medicaid