Healthcare Provider Details

I. General information

NPI: 1104601582
Provider Name (Legal Business Name): SHANTIKA DYKES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 BELL SHOALS RD
BRANDON FL
33511-8813
US

IV. Provider business mailing address

11404 WESTON POINTE DR APT 203
BRANDON FL
33511-2725
US

V. Phone/Fax

Practice location:
  • Phone: 813-360-1077
  • Fax:
Mailing address:
  • Phone: 813-360-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH24544
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: