Provider Demographics
NPI:1821601873
Name:CARTER, SHANNON L
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:CARTER
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 1:419 RACETRACK RD NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-4612
Mailing Address - Country:US
Mailing Address - Phone:850-362-6824
Mailing Address - Fax:
Practice Address - Street 1:419 RACETRACK RD NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-4612
Practice Address - Country:US
Practice Address - Phone:850-362-6824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-99956106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty