Provider Demographics
NPI:1649014424
Name:FAULK, SHANIAH DANAE
Entity type:Individual
Prefix:
First Name:SHANIAH
Middle Name:DANAE
Last Name:FAULK
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 1:2238 WHITE POND CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ALFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32420-6980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2934 HEADLAND AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-5828
Practice Address - Country:US
Practice Address - Phone:850-348-1057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician