Provider Demographics
NPI:1578673083
Name:FORTUNE, CAROL G (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:G
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 GOLDEN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32162-6765
Mailing Address - Country:US
Mailing Address - Phone:352-638-2264
Mailing Address - Fax:352-259-4050
Practice Address - Street 1:1522 GOLDEN RIDGE DR
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32162-6765
Practice Address - Country:US
Practice Address - Phone:352-638-2264
Practice Address - Fax:352-259-4050
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW80721041C0700X
MA1030651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6616Medicare ID - Type Unspecified