Provider Demographics
NPI:1053152728
Name:SHAFER, WANDA M
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:M
Last Name:SHAFER
Suffix:
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 1:2627 SHERMAN OAK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34289-2392
Mailing Address - Country:US
Mailing Address - Phone:512-709-5598
Mailing Address - Fax:
Practice Address - Street 1:2048 LARSON ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-6491
Practice Address - Country:US
Practice Address - Phone:941-999-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician