1518687433 NPI number — MIA I SHORTT

Table of content: SHANNON FREEBURN M.S. CCC-SLP (NPI 1033669569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518687433 NPI number — MIA I SHORTT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORTT
Provider First Name:
MIA
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1518687433
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 DEPAUW BLVD STE 3070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-6135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-324-0885
Provider Business Mailing Address Fax Number:
317-520-8200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3491 GANDY PARK
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PINELLAS PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33781-2656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-390-2211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2022

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: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 118316700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com