1336645779 NPI number — SUSAN A. SHIRLEY

Table of content: (NPI 1336645779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336645779 NPI number — SUSAN A. SHIRLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSAN A. SHIRLEY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1336645779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11778 SW BENNINTON CIRCLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST. LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-356-5486
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2440 SE FEDERAL HWY STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-4531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-356-5486
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SHIRLEY
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
LMHC
Authorized Official Telephone Number:
337-356-5486

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  8882 , 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: 60071Z761 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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