Provider Demographics
NPI:1003188087
Name:STICH, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:STICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 WRENN ST
Mailing Address - Street 2:
Mailing Address - City:TAVERNIER
Mailing Address - State:FL
Mailing Address - Zip Code:33070-2335
Mailing Address - Country:US
Mailing Address - Phone:305-809-5000
Mailing Address - Fax:305-809-5010
Practice Address - Street 1:175 WRENN ST
Practice Address - Street 2:
Practice Address - City:TAVERNIER
Practice Address - State:FL
Practice Address - Zip Code:33070-2335
Practice Address - Country:US
Practice Address - Phone:305-809-5000
Practice Address - Fax:305-809-5010
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator