Provider Demographics
NPI:1841067469
Name:KEITH, SHANICE J
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:J
Last Name:KEITH
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 1:4156 COVINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-5027
Mailing Address - Country:US
Mailing Address - Phone:407-761-4760
Mailing Address - Fax:
Practice Address - Street 1:2007 MAPLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:ZELLWOOD
Practice Address - State:FL
Practice Address - Zip Code:32798-5420
Practice Address - Country:US
Practice Address - Phone:407-761-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty