Provider Demographics
NPI:1780011387
Name:PROCTOR, SHAINA MARIE (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHAINA
Middle Name:MARIE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 RIVECON AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825
Mailing Address - Country:US
Mailing Address - Phone:786-246-2046
Mailing Address - Fax:
Practice Address - Street 1:1239 MOUNT VERNON ST FL 32803
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5417
Practice Address - Country:US
Practice Address - Phone:407-810-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11343235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002980000Medicaid