Provider Demographics
NPI:1881954584
Name:SOUCEK, MARY KATHERINE (MS, MSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:SOUCEK
Suffix:
Gender:F
Credentials:MS, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 TECHSTER BLVD
Mailing Address - Street 2:STE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-4805
Mailing Address - Country:US
Mailing Address - Phone:239-223-2751
Mailing Address - Fax:
Practice Address - Street 1:1940 MARAVILLA AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7135
Practice Address - Country:US
Practice Address - Phone:239-334-0222
Practice Address - Fax:239-334-0244
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW124681041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59-0192430Medicaid