MEDICARE: SHAUNA BISPHAM M.A., LMHC

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	101Y00000X	Counselor	MH15294	FL
2	103T00000X	Psychologist	MH15294	FL
3	101YM0800X	Mental Health Counselor	MH15294	FL

General Provider Information

NPI Number	:	1588032353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUNA BISPHAM M.A., LMHC

Provider Business Mailing Address
First Line	:	715 N WASHINGTON BLVD
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34236-4256
Country	:	US
Telephone Number	:	941-404-5557
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 N WASHINGTON BLVD
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34236-4256
Country	:	US
Telephone Number	:	941-404-5557
Fax Number	:

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

Provider Enumeration Date	:	09/09/2015
Last Update Date	:	10/09/2020

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