Provider Demographics
NPI:1326178310
Name:SHIODE PSYCHOTHERAPY, INC.
Entity Type:Organization
Organization Name:SHIODE PSYCHOTHERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHIODE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:702-384-4110
Mailing Address - Street 1:501 S. RANCHO DR.
Mailing Address - Street 2:STE I-64
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106
Mailing Address - Country:US
Mailing Address - Phone:702-384-4110
Mailing Address - Fax:702-384-7954
Practice Address - Street 1:501 S. RANCHO DR.
Practice Address - Street 2:STE I-64
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106
Practice Address - Country:US
Practice Address - Phone:702-384-4110
Practice Address - Fax:702-384-7954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0244103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002602062Medicaid
NVVPHD244Medicare ID - Type UnspecifiedMEDICARE ID-DAN