Provider Demographics
NPI:1275397937
Name:VINCENT, SHAN L
Entity Type:Individual
Prefix:
First Name:SHAN
Middle Name:L
Last Name:VINCENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 S GORDON RD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3738
Mailing Address - Country:US
Mailing Address - Phone:949-637-4091
Mailing Address - Fax:
Practice Address - Street 1:28 S GORDON RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3738
Practice Address - Country:US
Practice Address - Phone:949-637-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH25081101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health