Provider Demographics
NPI:1689248858
Name:HOLT, SHAKUANDA U
Entity Type:Individual
Prefix:MRS
First Name:SHAKUANDA
Middle Name:U
Last Name:HOLT
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 1:1815 NATCHEZ TRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-9042
Mailing Address - Country:US
Mailing Address - Phone:786-355-3781
Mailing Address - Fax:
Practice Address - Street 1:18425 NW 2ND AVE PH 5
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4524
Practice Address - Country:US
Practice Address - Phone:954-257-7473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1568103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty