Provider Demographics
NPI:1487798724
Name:SHELLEY, RACHEL DAWNE (BS, ITDS)
Entity type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:DAWNE
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:BS, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 NW COLQUITT WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4854
Mailing Address - Country:US
Mailing Address - Phone:386-752-6217
Mailing Address - Fax:
Practice Address - Street 1:346 NW COLQUITT WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4854
Practice Address - Country:US
Practice Address - Phone:386-752-6217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811863900Medicaid