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General NPI Number Information
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NPI Number | 1700214459
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Entity Type | Organization
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Legal Business Name | SHANLIS, INC.
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Dates
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Enumeration Date | 10/16/2013
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Last Update Date | 10/10/2016
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Provider Practice Location Address
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Address Line | 744 COLROADO AVE
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City | STUART
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State | FL
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Zip | 34994-2918
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Country | US
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Telephone | 772-223-9988
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Fax | 772-223-9593
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Provider Business Mailing Address
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Address Line | 744 COLROADO AVE
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City | STUART
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State | FL
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Zip | 34994-2918
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Country | US
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Telephone | 772-223-9988
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Fax | 772-223-9593
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. THEODORE G WILLIAMS
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Credential | PH.D.
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Telephone | 772-223-9988
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY5917
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License Number State | FL
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