=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720602527
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON E RAIKES M.ED., LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2020
-----------------------------------------------------
Last Update Date | 06/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13990 BARTRAM PARK BLVD UNIT 209
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-5543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-551-5365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13990 BARTRAM PARK BLVD UNIT 209
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-5543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-551-5365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | MH16624
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------