Provider Demographics
NPI:1255515185
Name:LICHTY, MARIBETH (ACSW,LCSW,CAP)
Entity type:Individual
Prefix:
First Name:MARIBETH
Middle Name:
Last Name:LICHTY
Suffix:
Gender:F
Credentials:ACSW,LCSW,CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5237 SUMMERLIN COMMONS BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-2158
Mailing Address - Country:US
Mailing Address - Phone:239-939-2939
Mailing Address - Fax:239-432-0161
Practice Address - Street 1:5237 SUMMERLIN COMMONS BLVD STE 235
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2158
Practice Address - Country:US
Practice Address - Phone:239-939-2939
Practice Address - Fax:239-432-0161
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW45481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ7810YMedicare PIN
FLS36555Medicare UPIN