Provider Demographics
NPI:1437962628
Name:DAVIS, SHAUNTAE (EDS, NCSP)
Entity type:Individual
Prefix:
First Name:SHAUNTAE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WOOD ARBOR LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7967
Mailing Address - Country:US
Mailing Address - Phone:850-583-1509
Mailing Address - Fax:
Practice Address - Street 1:9 WOOD ARBOR LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7967
Practice Address - Country:US
Practice Address - Phone:850-583-1509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1885103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool