Provider Demographics
NPI:1891902284
Name:FINE, SHELLY (MASC)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:
Last Name:FINE
Suffix:
Gender:F
Credentials:MASC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4480 DEERWOOD LAKE PKWY
Mailing Address - Street 2:#441
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2247
Mailing Address - Country:US
Mailing Address - Phone:904-620-8115
Mailing Address - Fax:904-620-8407
Practice Address - Street 1:7545 CENTURION PKWY
Practice Address - Street 2:#105
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0579
Practice Address - Country:US
Practice Address - Phone:904-620-8232
Practice Address - Fax:904-620-8407
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3289101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11587453OtherCAQH