Provider Demographics
NPI:1881209542
Name:SHANTELLE MOXIE, LLC
Entity type:Organization
Organization Name:SHANTELLE MOXIE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANTELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOXIE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:954-801-2411
Mailing Address - Street 1:13120 SW 44TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3101
Mailing Address - Country:US
Mailing Address - Phone:954-801-2411
Mailing Address - Fax:
Practice Address - Street 1:13120 SW 44TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3101
Practice Address - Country:US
Practice Address - Phone:954-801-2411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health