Provider Demographics
NPI:1972071181
Name:ALBRITTON, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ALBRITTON
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 1:1230 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:33839-3028
Mailing Address - Country:US
Mailing Address - Phone:863-832-2199
Mailing Address - Fax:
Practice Address - Street 1:3020 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803
Practice Address - Country:US
Practice Address - Phone:856-081-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12853101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health