Provider Demographics
NPI:1497428403
Name:JOSEPH, SHANICE
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:JOSEPH
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 1:4036 ELDRON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-6667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1475 COLLINGSWOOD BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1059
Practice Address - Country:US
Practice Address - Phone:941-999-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician