Healthcare Provider Details

I. General information

NPI: 1154541621
Provider Name (Legal Business Name): ELIZABETH SHANNON SEWELL M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. ELIZABETH SHANNON ROSE

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 HIGHWAY 71 STE A
MARIANNA FL
32446-1893
US

IV. Provider business mailing address

2860 HIGHWAY 71 STE A
MARIANNA FL
32446-1893
US

V. Phone/Fax

Practice location:
  • Phone: 850-323-1002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: