Provider Demographics
NPI:1194976308
Name:KATHRYN C SHAFER PHD PA
Entity type:Organization
Organization Name:KATHRYN C SHAFER PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-799-6789
Mailing Address - Street 1:675 W INDIANTOWN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7555
Mailing Address - Country:US
Mailing Address - Phone:561-799-6789
Mailing Address - Fax:561-575-7545
Practice Address - Street 1:675 W INDIANTOWN RD STE 100
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7555
Practice Address - Country:US
Practice Address - Phone:561-799-6789
Practice Address - Fax:561-575-7545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW22761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ2812Medicare PIN
FLS12063Medicare UPIN