Healthcare Provider Details

I. General information

NPI: 1124980800
Provider Name (Legal Business Name): SHAPE SPACE BEHAVIORAL SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 SANDPIPER PT
NEPTUNE BEACH FL
32266-1526
US

IV. Provider business mailing address

2000 SANDPIPER PT
NEPTUNE BEACH FL
32266-1526
US

V. Phone/Fax

Practice location:
  • Phone: 904-910-7393
  • Fax: 904-910-7393
Mailing address:
  • Phone: 904-910-7393
  • Fax: 904-910-7393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SHANNON BEACH NOWELL
Title or Position: BCBA/OWNER
Credential:
Phone: 904-910-7393