Provider Demographics
NPI:1003028119
Name:FORT MYERS PSYCHOLOGY, PA
Entity type:Organization
Organization Name:FORT MYERS PSYCHOLOGY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SLUDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-887-6004
Mailing Address - Street 1:8430 BELLE MEADE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-6009
Mailing Address - Country:US
Mailing Address - Phone:239-826-7903
Mailing Address - Fax:239-645-4777
Practice Address - Street 1:12791 WORLD PLAZA LN BLDG 89
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3989
Practice Address - Country:US
Practice Address - Phone:239-829-5494
Practice Address - Fax:239-645-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74129OtherBCBS FLORIDA
FLNJ5TQOtherBCBS-FL BLUE