Healthcare Provider Details

I. General information

NPI: 1932656899
Provider Name (Legal Business Name): POOJA SHASTRI PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13430 PARKER COMMONS BLVD STE 101
FORT MYERS FL
33912-1812
US

IV. Provider business mailing address

3606 TREASURE COVE CIR
NAPLES FL
34114-3983
US

V. Phone/Fax

Practice location:
  • Phone: 239-561-9955
  • Fax: 239-561-9779
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 9643
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPY 9643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: