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Provider Information for 1720602527


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SHANNON E RAIKES M.Ed., LMHC


Sex: Female

NPI: 1720602527
Last Updated: 2020-06-08
Certification Date: 2020-06-08

Details

NameValue
NPI1720602527
Enumeration Date2020-06-08
NPI TypeNPI-1 Individual
Sole ProprietorNO
StatusActive
Mailing Address 13990 BARTRAM PARK BLVD UNIT 209
JACKSONVILLE, FL 32258-5543
United States

Phone: 214-551-5365 | Fax:
 
Primary Practice Address 13990 BARTRAM PARK BLVD UNIT 209
JACKSONVILLE, FL 32258-5543
United States

Phone: 214-551-5365 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 101YM0800X - Counselor - Mental HealthFLMH16624