=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588723605
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IDEE B SHAPIRO LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 06/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 895 NAPA AVE. SUITE B-6
-----------------------------------------------------
City | MORRO BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-781-4725
-----------------------------------------------------
Fax | 805-781-4726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 895 NAPA AVE. SUITE B-6
-----------------------------------------------------
City | MORRO BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-781-4725
-----------------------------------------------------
Fax | 805-781-4726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT39394
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------