Provider Demographics
NPI:1295069748
Name:SMITH, SHANNAN NICOLE (BA, BCABA)
Entity type:Individual
Prefix:MS
First Name:SHANNAN
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:BA, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-3639
Mailing Address - Country:US
Mailing Address - Phone:813-468-3507
Mailing Address - Fax:
Practice Address - Street 1:1524 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-3639
Practice Address - Country:US
Practice Address - Phone:813-468-3507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-02-0510103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst