Provider Demographics
NPI:1396184248
Name:SHANLIS INC.
Entity Type:Organization
Organization Name:SHANLIS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:772-223-9988
Mailing Address - Street 1:744 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3005
Mailing Address - Country:US
Mailing Address - Phone:772-223-9988
Mailing Address - Fax:772-223-9593
Practice Address - Street 1:744 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3005
Practice Address - Country:US
Practice Address - Phone:772-223-9988
Practice Address - Fax:772-223-9593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-24
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5416103G00000X
103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1396184248Medicare UPIN