Provider Demographics
NPI:1780015214
Name:MIRRA, SHA'LEDA
Entity Type:Individual
Prefix:
First Name:SHA'LEDA
Middle Name:
Last Name:MIRRA
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 1:793 SW NAUTILUS RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-1335
Mailing Address - Country:US
Mailing Address - Phone:386-984-6618
Mailing Address - Fax:
Practice Address - Street 1:922 SW BAYA DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-4209
Practice Address - Country:US
Practice Address - Phone:386-697-8115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5724101YA0400X
FLSW117021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)