=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972954378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA E SHUTY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2016
-----------------------------------------------------
Last Update Date | 06/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 CYPRESS CLUB DR APT 805
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33060-4773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-799-1761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 CYPRESS CLUB DR APT 805
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33060-4773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-799-1761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW12863
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------