Provider Demographics
NPI:1821401431
Name:STEPHEN L MAGRUDER
Entity type:Organization
Organization Name:STEPHEN L MAGRUDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAGRUDER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:239-939-3700
Mailing Address - Street 1:12520 WORLD PLAZA LN
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3940
Mailing Address - Country:US
Mailing Address - Phone:239-939-3700
Mailing Address - Fax:239-939-3889
Practice Address - Street 1:12520 WORLD PLAZA LN
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3940
Practice Address - Country:US
Practice Address - Phone:239-939-3700
Practice Address - Fax:239-939-3889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW30061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ5641Medicare PIN