Healthcare Provider Details

I. General information

NPI: 1417911785
Provider Name (Legal Business Name): LORI T SHALLCROSS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W HWY 50 SUITE 104
CLERMONT FL
34711-2913
US

IV. Provider business mailing address

1450 BONNIE BURN CIR
WINTER PARK FL
32789-5703
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-5922
  • Fax: 352-360-6582
Mailing address:
  • Phone: 352-394-5922
  • Fax: 352-360-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 6675
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: