Provider Demographics
NPI:1144629320
Name:PROUDFIT, SHANNA
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:PROUDFIT
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 1:12920 SW 133RD CT UNIT 11
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6149
Mailing Address - Country:US
Mailing Address - Phone:786-475-5732
Mailing Address - Fax:844-455-3224
Practice Address - Street 1:12920 SW 133RD CT UNIT 11
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6149
Practice Address - Country:US
Practice Address - Phone:786-475-5732
Practice Address - Fax:844-455-3224
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FLRBT-18-49965106S00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program