MEDICARE: DR. JERROLD LEE SHAPIRO PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY5646	CA

General Provider Information

NPI Number	:	1063633535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERROLD LEE SHAPIRO PH.D.

Provider Business Mailing Address
First Line	:	385 VERANO DR
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94022-2345
Country	:	US
Telephone Number	:	650-948-7292
Fax Number	:

Provider Business Practice Location Address
First Line	:	4546 EL CAMINO REAL
Second Line	:	SUITE 242
City	:	LOS ALTOS
State	:	CA
Zip	:	94022-1099
Country	:	US
Telephone Number	:	650-941-9219
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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