Basic Information
| Provider Information | |||||||||
| NPI: | 1104180280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARSEMA | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOSTER | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 430 MORTON PLANT ST STE 401 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272986025 | ||||||||
| FaxNumber: | 7274618648 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 MORTON PLANT ST | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274618635 | ||||||||
| FaxNumber: | 7273336038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2012 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0700X | PY 9339 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TC0700X | PY 9339 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103G00000X | PY 9339 | FL | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | P01713937 | 01 | FL | RAILROAD MEDICARE PROVIDER NUMBER | OTHER | 023608600 | 05 | FL | MEDICAID |