Provider Demographics
NPI:1063019057
Name:ANDERSON, SHAUN MICHAEL
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:MICHAEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 S MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-6585
Mailing Address - Country:US
Mailing Address - Phone:352-363-5410
Mailing Address - Fax:
Practice Address - Street 1:235 S MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-6585
Practice Address - Country:US
Practice Address - Phone:352-363-5410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-03
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19279101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health