MEDICARE: MR. ALLEN EDGAR SHEALY 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	103T00000X	Psychologist	AL#100	AL

General Provider Information

NPI Number	:	1891887188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALLEN EDGAR SHEALY PHD

Provider Business Mailing Address
First Line	:	1613 21ST ST SO
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35205-4952
Country	:	US
Telephone Number	:	205-933-7849
Fax Number	:	205-933-7880

Provider Business Practice Location Address
First Line	:	1613 21ST ST SO
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35205-4952
Country	:	US
Telephone Number	:	205-933-7849
Fax Number	:	205-933-7880

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	05/24/2011

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