Provider Demographics
NPI:1730480583
Name:SHIR, JODI SAMUELS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:SAMUELS
Last Name:SHIR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12651 W SUNRISE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-0906
Mailing Address - Country:US
Mailing Address - Phone:954-587-7520
Mailing Address - Fax:954-587-7527
Practice Address - Street 1:12651 W SUNRISE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-0906
Practice Address - Country:US
Practice Address - Phone:954-587-7520
Practice Address - Fax:954-587-7527
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5687103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent