Provider Demographics
NPI:1194232140
Name:CREDLE, SHANEQWA
Entity type:Individual
Prefix:
First Name:SHANEQWA
Middle Name:
Last Name:CREDLE
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 1:1823 BUSINESS PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1230
Mailing Address - Country:US
Mailing Address - Phone:386-254-1931
Mailing Address - Fax:
Practice Address - Street 1:1823 BUSINESS PARK BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1230
Practice Address - Country:US
Practice Address - Phone:386-254-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid