Provider Demographics
NPI:1134907900
Name:TUBBS, SHANNON D
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:TUBBS
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 1:28210 HOLLONDEL RD
Mailing Address - Street 2:
Mailing Address - City:OKAHUMPKA
Mailing Address - State:FL
Mailing Address - Zip Code:34762-3325
Mailing Address - Country:US
Mailing Address - Phone:352-455-3929
Mailing Address - Fax:
Practice Address - Street 1:28210 HOLLONDEL RD
Practice Address - Street 2:
Practice Address - City:OKAHUMPKA
Practice Address - State:FL
Practice Address - Zip Code:34762-3325
Practice Address - Country:US
Practice Address - Phone:352-455-3929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician