Provider Demographics
NPI:1689822686
Name:DAVIS, SHANE K (LMHC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:K
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 26TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-7200
Mailing Address - Country:US
Mailing Address - Phone:269-282-4298
Mailing Address - Fax:
Practice Address - Street 1:4515 26TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-7200
Practice Address - Country:US
Practice Address - Phone:269-282-4298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23035101YM0800X
MI6301013040103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301013040OtherLICENSE