Provider Demographics
NPI:1780600858
Name:EZELL, SHAUNA M (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:SHAUNA
Middle Name:M
Last Name:EZELL
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:MS
Other - First Name:SHAUNA
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 MEDICAL GROUP
Mailing Address - Street 2:340 MAGNOLIA CIRCLE, BLDG 1465
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403-5604
Mailing Address - Country:US
Mailing Address - Phone:850-283-7370
Mailing Address - Fax:
Practice Address - Street 1:325TH MEDICAL GROUP
Practice Address - Street 2:340 MAGNOLIA CIRCLE, BLDG. 1465
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403-5604
Practice Address - Country:US
Practice Address - Phone:850-283-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7400-1231041C0700X, 1041C0700X
WI3097-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN524139100Medicaid
MN800001659Medicare ID - Type Unspecified