Provider Demographics
NPI:1821689985
Name:SHIDEMANTLE, ELIZABETH INEZ (BS MS CAC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:INEZ
Last Name:SHIDEMANTLE
Suffix:
Gender:F
Credentials:BS MS CAC
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Mailing Address - Street 1:105 W SEMINOLE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2933
Mailing Address - Country:US
Mailing Address - Phone:321-339-8560
Mailing Address - Fax:
Practice Address - Street 1:1600 SARNO RD STE 3
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4992
Practice Address - Country:US
Practice Address - Phone:321-622-6290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor