Healthcare Provider Details

I. General information

NPI: 1639320534
Provider Name (Legal Business Name): BONNIE KEELING SCHAMBACK MA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 COLORADO AVE
STUART FL
34994
US

IV. Provider business mailing address

101 COLORADO AVE
STUART FL
34994
US

V. Phone/Fax

Practice location:
  • Phone: 772-220-3255
  • Fax:
Mailing address:
  • Phone: 772-220-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC0002621
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: