Provider Demographics
NPI:1063948248
Name:BLACK, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BLACK
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 1:2681 ROOSEVELT BLVD
Mailing Address - Street 2:APT 6107
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-2962
Mailing Address - Country:US
Mailing Address - Phone:305-619-5739
Mailing Address - Fax:
Practice Address - Street 1:550 N REO ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1061
Practice Address - Country:US
Practice Address - Phone:813-374-2070
Practice Address - Fax:813-337-0937
Is Sole Proprietor?:No
Enumeration Date:2017-05-07
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist