1780600858 NPI number — DR. SHAUNA M. EZELL PHD, LCSW

Table of content: DR. SHAUNA M. EZELL PHD, LCSW (NPI 1780600858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780600858 NPI number — DR. SHAUNA M. EZELL PHD, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EZELL
Provider First Name:
SHAUNA
Provider Middle Name:
M.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
SHAUNA
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780600858
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 MEDICAL GROUP
Provider Second Line Business Mailing Address:
340 MAGNOLIA CIRCLE, BLDG 1465
Provider Business Mailing Address City Name:
TYNDALL AFB
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32403-5604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-283-7370
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325TH MEDICAL GROUP
Provider Second Line Business Practice Location Address:
340 MAGNOLIA CIRCLE, BLDG. 1465
Provider Business Practice Location Address City Name:
TYNDALL AFB
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32403-5604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-283-7511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  7400-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 3097-57 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 524139100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".