1417911785 NPI number — LORI T SHALLCROSS LCSW

Table of content: LORI T SHALLCROSS LCSW (NPI 1417911785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417911785 NPI number — LORI T SHALLCROSS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHALLCROSS
Provider First Name:
LORI
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417911785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 BONNIE BURN CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32789-5703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-394-5922
Provider Business Mailing Address Fax Number:
352-360-6582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 W HWY 50
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34711-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-394-5922
Provider Business Practice Location Address Fax Number:
352-360-6582
Provider Enumeration Date:
04/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW 6675 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Z090N . This is a "BLUE CROSS BLUE SHIELD #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com