Basic Information
| Provider Information | |||||||||
| NPI: | 1457401564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHINOHARA | ||||||||
| FirstName: | SUMIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1000 JEFFERSON ST. | ||||||||
| Address2: | STE. 2C | ||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173790496 | ||||||||
| FaxNumber: | 6178070958 | ||||||||
| Practice Location | |||||||||
| Address1: | 872 MASSACHUSETTS AVE. | ||||||||
| Address2: | STE. 2-2, 2-7 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173955806 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 8645 | MA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 8645 | MA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.