MEDICARE: SHANI PEEBLES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1043684509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANI PEEBLES

Provider Business Mailing Address
First Line	:	7400 BEAUFONT SPRINGS DR
Second Line	:	SUITE 300
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23225-5556
Country	:	US
Telephone Number	:	252-333-4787
Fax Number	:

Provider Business Practice Location Address
First Line	:	7400 BEAUFONT SPRINGS DR
Second Line	:	SUITE 300
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23225-5556
Country	:	US
Telephone Number	:	252-333-4787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2015
Last Update Date	:	11/20/2015

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