=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255137014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLY M PARKS LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2025
-----------------------------------------------------
Last Update Date | 05/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9886 JENO RD
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32583-9345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-392-0088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5545 SAUFLEY FIELD RD
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32526-9479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-392-0088
-----------------------------------------------------
Fax | 520-844-6919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LAC-23360
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------