Healthcare Provider Details

I. General information

NPI: 1841032760
Provider Name (Legal Business Name): SHANTANIQUE DALEJA MOORE KING LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 W LAKE MARY BLVD STE 308B
LAKE MARY FL
32746-3564
US

IV. Provider business mailing address

12259 FOX HOUND LN
ORLANDO FL
32826-3666
US

V. Phone/Fax

Practice location:
  • Phone: 407-214-3471
  • Fax: 407-602-0961
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT4951
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: