Healthcare Provider Details

I. General information

NPI: 1396184248
Provider Name (Legal Business Name): SHANLIS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 COLORADO AVE
STUART FL
34994-3005
US

IV. Provider business mailing address

744 COLORADO AVE
STUART FL
34994-3005
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-9988
  • Fax: 772-223-9593
Mailing address:
  • Phone: 772-223-9988
  • Fax: 772-223-9593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY5416
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN EDNEY
Title or Position: DIRECTOR OF OPERATIONS
Credential: PSY.D
Phone: 772-223-9988