Healthcare Provider Details

I. General information

NPI: 1134423254
Provider Name (Legal Business Name): SHEA EASTERWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 ALMA DR.
PLANO TX
75023
US

IV. Provider business mailing address

PO BOX 828
MCKINNEY TX
75070
US

V. Phone/Fax

Practice location:
  • Phone: 972-422-5939
  • Fax: 972-509-0923
Mailing address:
  • Phone: 972-562-0190
  • Fax: 972-562-3647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number65275
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: