Provider Demographics
NPI:1952503021
Name:BOSS, SHANTALA MARIE (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:SHANTALA
Middle Name:MARIE
Last Name:BOSS
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 1:1255 SAINT ALBANS LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1979
Mailing Address - Country:US
Mailing Address - Phone:407-271-9552
Mailing Address - Fax:
Practice Address - Street 1:101 TIMBERLACHEN CIRCLE
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:407-308-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8920101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health