=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548541048
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNA BROOKE HEUN PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2011
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 S SHARON AMITY RD STE 350
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28211-3099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-802-5468
-----------------------------------------------------
Fax | 704-800-5768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 CHANNELSIDE DRIVE 2414
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-507-1508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | PY 8953
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 5173
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------