Healthcare Provider Details

I. General information

NPI: 1376459784
Provider Name (Legal Business Name): SHANNON L BERTHIAUME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7238 DAVIT CIR
LAKE WORTH FL
33467-7781
US

IV. Provider business mailing address

114 BELLA VISTA WAY
ROYAL PALM BEACH FL
33411-4308
US

V. Phone/Fax

Practice location:
  • Phone: 774-823-6079
  • Fax:
Mailing address:
  • Phone: 774-823-6079
  • Fax: 774-539-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: