Provider Demographics
NPI:1275870495
Name:PHELPS, SHAUN MYKEL (LMHC)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:MYKEL
Last Name:PHELPS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2756
Mailing Address - Country:US
Mailing Address - Phone:850-215-6007
Mailing Address - Fax:850-215-6003
Practice Address - Street 1:2711 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1366
Practice Address - Country:US
Practice Address - Phone:850-769-6001
Practice Address - Fax:850-769-6003
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11568101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health