Provider Demographics
NPI:1700214459
Name:SHANLIS, INC.
Entity Type:Organization
Organization Name:SHANLIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:772-223-9988
Mailing Address - Street 1:744 COLROADO AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2918
Mailing Address - Country:US
Mailing Address - Phone:772-223-9988
Mailing Address - Fax:772-223-9593
Practice Address - Street 1:744 COLROADO AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2918
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:2013-10-16
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1700214459Medicare UPIN
FL1043502966Medicare UPIN
FL1477982536Medicare UPIN
FL1497114359Medicare UPIN