Provider Demographics
NPI:1619788213
Name:CAICEDO, SHANNON MARY
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARY
Last Name:CAICEDO
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 1:5 AUTUMN BREEZE WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3806
Mailing Address - Country:US
Mailing Address - Phone:786-452-2264
Mailing Address - Fax:
Practice Address - Street 1:1060 W STATE ROAD 434 STE 108
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4953
Practice Address - Country:US
Practice Address - Phone:407-324-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-387446106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician