Provider Demographics
NPI:1093930968
Name:MARNIE G. SHANBHAG, PH.D., P.A.
Entity Type:Organization
Organization Name:MARNIE G. SHANBHAG, PH.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANBHAG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:407-644-5598
Mailing Address - Street 1:505 N PARK AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3268
Mailing Address - Country:US
Mailing Address - Phone:407-644-5598
Mailing Address - Fax:407-644-0329
Practice Address - Street 1:505 N PARK AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3268
Practice Address - Country:US
Practice Address - Phone:407-644-5598
Practice Address - Fax:407-644-0329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6016103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty