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General NPI Number Information
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NPI Number | 1821689985
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Entity Type | Individual
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Provider Name | ELIZABETH INEZ SHIDEMANTLE BS MS CAC
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Gender | Female
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Dates
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Enumeration Date | 02/01/2021
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Last Update Date | 02/01/2021
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Provider Practice Location Address
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Address Line | 1600 SARNO RD STE 3
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City | MELBOURNE
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State | FL
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Zip | 32935-4992
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Country | US
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Telephone | 321-622-6290
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Fax |
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Provider Business Mailing Address
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Address Line | 105 W SEMINOLE AVE APT 1
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City | MELBOURNE
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State | FL
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Zip | 32901-2933
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Country | US
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Telephone | 321-339-8560
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225C00000X
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Taxonomy Name | Rehabilitation Counselor
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License Number |
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License Number State |
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