Provider Demographics
NPI:1497260665
Name:PRINCE, SHANNON S (MA, BCBA, LBA, ITDS)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:S
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MA, BCBA, LBA, ITDS
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:S
Other - Last Name:CHATMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA, LBA
Mailing Address - Street 1:2800 OKEECHOBEE RD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4613
Mailing Address - Country:US
Mailing Address - Phone:772-233-6446
Mailing Address - Fax:772-264-3990
Practice Address - Street 1:2800 OKEECHOBEE RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4613
Practice Address - Country:US
Practice Address - Phone:772-233-6446
Practice Address - Fax:772-264-3990
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-09
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
FL1-23-67173103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023279500Medicaid