MEDICARE: SHAMISO WELLNESS INSTITUTE

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1205782166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAMISO WELLNESS INSTITUTE

Provider Business Mailing Address
First Line	:	145 NORTHCUTT TER
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32317-7216
Country	:	US
Telephone Number	:	850-294-6906
Fax Number	:	850-807-5214

Provider Business Practice Location Address
First Line	:	1607 VILLAGE SQUARE BLVD STE 5
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32309-2772
Country	:	US
Telephone Number	:	850-294-6906
Fax Number	:	850-807-5214

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. SARAH TISTSI MBIZA
Credential	:	PHD
Telephone Number	:	850-294-6906

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	03/04/2026

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Directions to “SHAMISO WELLNESS INSTITUTE ” Practice Location

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