Healthcare Provider Details

I. General information

NPI: 1063784577
Provider Name (Legal Business Name): LAURA SLAP-SHELTON, PSY.D,PA,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 WEST COLE ROAD
BIDDEFORD ME
04005
US

IV. Provider business mailing address

28 WEST COLE ROAD
BIDDEFORD ME
04005
US

V. Phone/Fax

Practice location:
  • Phone: 207-294-7471
  • Fax:
Mailing address:
  • Phone: 207-294-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS980
License Number StateME

VIII. Authorized Official

Name: LAURA SLAP-SHELTON
Title or Position: OWNER
Credential: PSY.D
Phone: 207-294-7471