Provider Demographics
NPI:1497795371
Name:ROSSI, KRISTAL LAMB (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:LAMB
Last Name:ROSSI
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1400
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:12550 NEW BRITTANY BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3655
Practice Address - Country:US
Practice Address - Phone:239-936-1114
Practice Address - Fax:239-936-5968
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1846C2084P0800X
FLSW98861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q67623Medicare UPIN