Provider Demographics
NPI:1861757411
Name:VICKERS, SHANAWANA LETESE' (BA/CM)
Entity type:Individual
Prefix:MRS
First Name:SHANAWANA
Middle Name:LETESE'
Last Name:VICKERS
Suffix:
Gender:F
Credentials:BA/CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5664 SW 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-5677
Mailing Address - Country:US
Mailing Address - Phone:352-351-6900
Mailing Address - Fax:
Practice Address - Street 1:717 SW MARTIN LUTHER KING JR AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-1435
Practice Address - Country:US
Practice Address - Phone:352-351-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76119900Medicaid