=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932846706
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWNA JAMIE STOTTS PSYD, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2022
-----------------------------------------------------
Last Update Date | 05/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 96 SW ALLAPATTAH RD
-----------------------------------------------------
City | INDIANTOWN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34956-4307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-597-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1521 ALTON RD UNIT 310
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33139-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-978-6669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY34972
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY11329
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number | PY11329
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW14934
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------