Basic Information
Provider Information | |||||||||
NPI: | 1780600858 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EZELL | ||||||||
FirstName: | SHAUNA | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD, LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOHNSON | ||||||||
OtherFirstName: | SHAUNA | ||||||||
OtherMiddleName: | M. | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 325 MEDICAL GROUP | ||||||||
Address2: | 340 MAGNOLIA CIRCLE, BLDG 1465 | ||||||||
City: | TYNDALL AFB | ||||||||
State: | FL | ||||||||
PostalCode: | 324035604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502837370 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 325TH MEDICAL GROUP | ||||||||
Address2: | 340 MAGNOLIA CIRCLE, BLDG. 1465 | ||||||||
City: | TYNDALL AFB | ||||||||
State: | FL | ||||||||
PostalCode: | 324035604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502837511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 04/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7400-123 | WI | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103TC0700X | 3097-57 | WI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 524139100 | 05 | MN |   | MEDICAID |