Provider Demographics
NPI:1689222473
Name:WRIGHT, SHALANE ROCHELLE
Entity Type:Individual
Prefix:
First Name:SHALANE
Middle Name:ROCHELLE
Last Name:WRIGHT
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 1:2466 NW 44TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-4552
Mailing Address - Country:US
Mailing Address - Phone:305-731-8821
Mailing Address - Fax:
Practice Address - Street 1:429 SW 14TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2317
Practice Address - Country:US
Practice Address - Phone:305-731-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020589000Medicaid