Provider Demographics
NPI:1093462277
Name:SHAVER SCHLABACH, TRACY DARLENE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DARLENE
Last Name:SHAVER SCHLABACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7325 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-4603
Mailing Address - Country:US
Mailing Address - Phone:727-424-6199
Mailing Address - Fax:
Practice Address - Street 1:7325 10TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-4603
Practice Address - Country:US
Practice Address - Phone:727-424-6199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113704700Medicaid