Provider Demographics
NPI:1811231061
Name:MCFAULS, SHANNON KELLY (LMHC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KELLY
Last Name:MCFAULS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:
Practice Address - Street 1:463380 STATE ROAD 200 UNIT B
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3240
Practice Address - Country:US
Practice Address - Phone:904-500-9808
Practice Address - Fax:904-432-0401
Is Sole Proprietor?:No
Enumeration Date:2012-11-11
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17398101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health