Healthcare Provider Details

I. General information

NPI: 1821910415
Provider Name (Legal Business Name): JOSIAH SHIVELY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 E BLOOMINGDALE AVE
BRANDON FL
33511-8101
US

IV. Provider business mailing address

130 E BLOOMINGDALE AVE
BRANDON FL
33511-8101
US

V. Phone/Fax

Practice location:
  • Phone: 813-444-8760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number29601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: