Provider Demographics
NPI:1629264338
Name:DALEIDEN,, SHANNON MICHELE (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELE
Last Name:DALEIDEN,
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 GRANT CT
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3945
Mailing Address - Country:US
Mailing Address - Phone:808-781-4750
Mailing Address - Fax:321-426-9054
Practice Address - Street 1:665 GRANT CT
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-3945
Practice Address - Country:US
Practice Address - Phone:808-781-4750
Practice Address - Fax:321-426-9054
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK885103TH0100X
FLPY7584103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service