Healthcare Provider Details

I. General information

NPI: 1255137014
Provider Name (Legal Business Name): SHELLY M PARKS LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W GREGORY ST
PENSACOLA FL
32502-4820
US

IV. Provider business mailing address

112 W GREGORY ST
PENSACOLA FL
32502-4820
US

V. Phone/Fax

Practice location:
  • Phone: 520-392-0088
  • Fax:
Mailing address:
  • Phone: 520-392-0088
  • Fax: 520-844-6919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number29283
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-23360
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: