Provider Demographics
NPI:1639919798
Name:FRITH, SHANTAY GERONICA
Entity type:Individual
Prefix:
First Name:SHANTAY
Middle Name:GERONICA
Last Name:FRITH
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 1:1850 SE 18TH AVE APT 2407
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-8261
Mailing Address - Country:US
Mailing Address - Phone:786-676-1697
Mailing Address - Fax:
Practice Address - Street 1:11808 N OHIO ST
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431-6724
Practice Address - Country:US
Practice Address - Phone:352-342-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-349941106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician