Provider Demographics
NPI:1215917711
Name:MARRIAGE AND FAMILY CENTER
Entity type:Organization
Organization Name:MARRIAGE AND FAMILY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-939-2939
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW45481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ7810OtherBLUE CROSS/ BLUE SHIELD
FLS36555Medicare UPIN
FLFO127AMedicare PIN