Healthcare Provider Details

I. General information

NPI: 1700214459
Provider Name (Legal Business Name): SHANLIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 COLROADO AVE
STUART FL
34994-2918
US

IV. Provider business mailing address

744 COLROADO AVE
STUART FL
34994-2918
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 Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY5917
License Number StateFL

VIII. Authorized Official

Name: DR. THEODORE G WILLIAMS
Title or Position: CLINICAL DIRECTOR
Credential: PH.D.
Phone: 772-223-9988