Provider Demographics
NPI:1982791687
Name:SHEA, MARY ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:SHEA
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 1:1338 S HIAWASSEE RD
Mailing Address - Street 2:APT. 118
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5785
Mailing Address - Country:US
Mailing Address - Phone:803-466-5309
Mailing Address - Fax:
Practice Address - Street 1:6937 MEDICAL VIEW LN
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-6648
Practice Address - Country:US
Practice Address - Phone:813-780-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC528103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPSO195Medicaid