Provider Demographics
NPI:1518431956
Name:STAGNER, SHAMINA
Entity Type:Individual
Prefix:
First Name:SHAMINA
Middle Name:
Last Name:STAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAMINA
Other - Middle Name:
Other - Last Name:STAGNER-RAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6912 AMARILLO ST
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-3899
Mailing Address - Country:US
Mailing Address - Phone:727-247-2236
Mailing Address - Fax:
Practice Address - Street 1:2750 N MCMULLEN BOOTH RD STE 102E
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3362
Practice Address - Country:US
Practice Address - Phone:727-547-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH17922101YM0800X
FLMH18797101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty