Provider Demographics
NPI:1700903796
Name:CORDELL, TINA MARIE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:CORDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8961 DANIELS CENTER DR STE 401
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-0314
Mailing Address - Country:US
Mailing Address - Phone:239-433-6700
Mailing Address - Fax:239-433-6703
Practice Address - Street 1:8961 DANIELS CENTER DR STE 401
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-0314
Practice Address - Country:US
Practice Address - Phone:239-433-6700
Practice Address - Fax:239-433-6703
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL757777000Medicaid