Healthcare Provider Details

I. General information

NPI: 1700170446
Provider Name (Legal Business Name): MARK SHATS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2011
Last Update Date: 05/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4254 LENNOX DR
MIAMI FL
33133-6721
US

IV. Provider business mailing address

4219 ANNE CT
MIAMI FL
33133-6626
US

V. Phone/Fax

Practice location:
  • Phone: 415-717-8146
  • Fax:
Mailing address:
  • Phone: 415-717-8146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY8156
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY8156
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY8156
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPY8156
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY8156
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPY8156
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: