=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891334157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POOJA SHASTRI, PSY.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2020
-----------------------------------------------------
Last Update Date | 01/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13430 PARKER COMMONS BLVD STE 101
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-561-9955
-----------------------------------------------------
Fax | 239-561-9779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3606 TREASURE COVE CIR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34114-3983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. POOJA SHASTRI
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 773-677-2170
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------