MEDICARE: SHAPREE SUMMERVILLE PHD

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	103TC0700X	Clinical Psychologist	P.08665	OH

General Provider Information

NPI Number	:	1578931572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAPREE SUMMERVILLE PHD

Provider Business Mailing Address
First Line	:	5425 FISHBURG RD
Second Line	:	P.O. BOX 24111
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-7500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6545 MARKET AVE N STE 100
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-2430
Country	:	US
Telephone Number	:	937-303-1209
Fax Number	:

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

Provider Enumeration Date	:	09/08/2015
Last Update Date	:	02/06/2026

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