Healthcare Provider Details

I. General information

NPI: 1932864170
Provider Name (Legal Business Name): SHANIYA MARDRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 FAYETTEVILLE ST STE 1100
RALEIGH NC
27601-3000
US

IV. Provider business mailing address

500 FAIRWAY DR STE 102
DEERFIELD BEACH FL
33441-1817
US

V. Phone/Fax

Practice location:
  • Phone: 919-987-2240
  • Fax:
Mailing address:
  • Phone: 877-418-2978
  • Fax: 866-500-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number4021
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: