MEDICARE: BISPHAM PSYCHOTHERAPY INC.

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	101Y00000X	Counselor	MH15294	FL

General Provider Information

NPI Number	:	1871084822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BISPHAM PSYCHOTHERAPY INC.

Provider Business Mailing Address
First Line	:	715 N WASHINGTON BLVD STE A
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34236-4256
Country	:	US
Telephone Number	:	941-404-5557
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 N WASHINGTON BLVD STE A
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34236-4256
Country	:	US
Telephone Number	:	941-404-5557
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHAUNA BISPHAM
Credential	:	LMHC
Telephone Number	:	941-544-1303

Provider Enumeration Date	:	05/25/2018
Last Update Date	:	10/09/2020

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