Provider Demographics
NPI:1003497108
Name:SMITH, SHANNA MARIE
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:MARIE
Other - Last Name:GRAVITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6185 TISDALE LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-4291
Mailing Address - Country:US
Mailing Address - Phone:850-450-8838
Mailing Address - Fax:
Practice Address - Street 1:1331 CREIGHTON RD STE B
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-9403
Practice Address - Country:US
Practice Address - Phone:850-450-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107288400Medicaid