Healthcare Provider Details

I. General information

NPI: 1578937918
Provider Name (Legal Business Name): SHANIQUE EBANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W PROSPECT RD
FORT LAUDERDALE FL
33309-2519
US

IV. Provider business mailing address

4740 N STATE ROAD 7
LAUDERDALE LAKES FL
33319-5839
US

V. Phone/Fax

Practice location:
  • Phone: 954-731-5100
  • Fax:
Mailing address:
  • Phone: 954-486-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW14586
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14586
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: