Healthcare Provider Details

I. General information

NPI: 1801490685
Provider Name (Legal Business Name): STEPHANIE WILLIS-SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NW 165TH STREET RD STE 100
MIAMI FL
33169-6306
US

IV. Provider business mailing address

5514 DOGWOOD WAY
TAMARAC FL
33319-5111
US

V. Phone/Fax

Practice location:
  • Phone: 786-657-2272
  • Fax:
Mailing address:
  • Phone: 954-687-2347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: