Provider Demographics
NPI:1609565688
Name:HARRIS, SHANIQUE ROCHELLE
Entity Type:Individual
Prefix:
First Name:SHANIQUE
Middle Name:ROCHELLE
Last Name:HARRIS
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 1:1422 NW 47TH TER
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33063-3955
Mailing Address - Country:US
Mailing Address - Phone:954-673-2039
Mailing Address - Fax:
Practice Address - Street 1:725 N HIGHWAY A1A STE A104
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-4561
Practice Address - Country:US
Practice Address - Phone:561-446-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician