Provider Demographics
NPI:1023705407
Name:GRACE, SHANITA SHAN
Entity type:Individual
Prefix:
First Name:SHANITA
Middle Name:SHAN
Last Name:GRACE
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 1:506 NW 3RD ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DANIA
Mailing Address - State:FL
Mailing Address - Zip Code:33004-2701
Mailing Address - Country:US
Mailing Address - Phone:754-273-0262
Mailing Address - Fax:
Practice Address - Street 1:506 NW 3RD ST APT 2
Practice Address - Street 2:
Practice Address - City:DANIA
Practice Address - State:FL
Practice Address - Zip Code:33004-2701
Practice Address - Country:US
Practice Address - Phone:754-273-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician