Healthcare Provider Details

I. General information

NPI: 1104180280
Provider Name (Legal Business Name): SHANNON MARIE BARSEMA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MARIE FOSTER PHD

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MORTON PLANT ST SUITE 402
CLEARWATER FL
33756-3398
US

IV. Provider business mailing address

430 MORTON PLANT ST STE 401
CLEARWATER FL
33756-3394
US

V. Phone/Fax

Practice location:
  • Phone: 727-461-8635
  • Fax: 727-333-6038
Mailing address:
  • Phone: 727-298-6025
  • Fax: 727-461-8648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPY 9339
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 9339
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY 9339
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: