Healthcare Provider Details

I. General information

NPI: 1548747181
Provider Name (Legal Business Name): SHANNON MARIE SMITH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 1ST ST S STE 100A
WINTER HAVEN FL
33880-3904
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 863-280-6080
  • Fax: 863-229-7587
Mailing address:
  • Phone: 727-532-1355
  • Fax: 813-635-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY10219
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: