=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952503021
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANTALA MARIE BOSS LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 08/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 TIMBERLACHEN CIRCLE SUITE 101
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-308-0122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1255 SAINT ALBANS LOOP
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-1979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-271-9552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH8920
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------