Healthcare Provider Details

I. General information

NPI: 1841805512
Provider Name (Legal Business Name): SHAWN MORDHORST PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 RIVERSIDE CIR
ROANOKE VA
24016-4955
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-526-1400
  • Fax: 540-985-9412
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number023778
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810007324
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: