MEDICARE: DR. MAUDE GUILMETTE SHANNON PHD, PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	PY12587	FL
2	103T00000X	Psychologist	PY12587	FL
3	103TC0700X	Clinical Psychologist	PY12587	FL
4	103TE1100X	Exercise & Sports Psychologist	PY12587	FL

General Provider Information

NPI Number	:	1003628934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAUDE GUILMETTE SHANNON PHD, PSYD

Provider Business Mailing Address
First Line	:	1624 NE 16TH TER
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33305-3410
Country	:	US
Telephone Number	:	954-224-5262
Fax Number	:

Provider Business Practice Location Address
First Line	:	1624 NE 16TH TER
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33305-3410
Country	:	US
Telephone Number	:	438-834-1563
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	06/06/2026

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