Basic Information
| Provider Information | |||||||||
| NPI: | 1942550033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCSHAN | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | ALBERTHA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAMILTON | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 639 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327680639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213624176 | ||||||||
| FaxNumber: | 3523600762 | ||||||||
| Practice Location | |||||||||
| Address1: | 2110 N DONNELLY ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | MOUNT DORA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327576968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213624176 | ||||||||
| FaxNumber: | 3212565176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2012 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SW12807 | FL | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | SW12807 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.