Provider Demographics
NPI:1063901403
Name:EGLY, SHELEAHA C I
Entity type:Individual
Prefix:MRS
First Name:SHELEAHA
Middle Name:C
Last Name:EGLY
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 MIDDLE ST UNIT 1201
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3625
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:29288 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761
Practice Address - Country:US
Practice Address - Phone:727-351-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician