Provider Demographics
NPI:1922775352
Name:LOTT, SHANIQUN NICOLE
Entity Type:Individual
Prefix:MRS
First Name:SHANIQUN
Middle Name:NICOLE
Last Name:LOTT
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 1:708 NAVARRO DR APT C
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6615
Mailing Address - Country:US
Mailing Address - Phone:346-332-2460
Mailing Address - Fax:
Practice Address - Street 1:3841 SAGEBRIAR DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-6107
Practice Address - Country:US
Practice Address - Phone:979-985-9503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician