Healthcare Provider Details

I. General information

NPI: 1417238437
Provider Name (Legal Business Name): SHAWNTANNA D PROCTOR A.A.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2011
Last Update Date: 09/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 NE 14TH ST SUITE 5
POMPANO BEACH FL
33062-3565
US

IV. Provider business mailing address

1801 DALLAS AVE
CHARLOTTE NC
28205-7905
US

V. Phone/Fax

Practice location:
  • Phone: 888-880-9270
  • Fax:
Mailing address:
  • Phone: 704-493-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: