MEDICARE: MY THERAPIST SHANNON LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1619777430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY THERAPIST SHANNON LLC

Provider Business Mailing Address
First Line	:	1540 NAVAHO AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-1134
Country	:	US
Telephone Number	:	904-513-0379
Fax Number	:

Provider Business Practice Location Address
First Line	:	1540 NAVAHO AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-1134
Country	:	US
Telephone Number	:	904-513-0379
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. SHANNON MCFAULS
Credential	:	LMHC
Telephone Number	:	904-513-0379

Provider Enumeration Date	:	03/19/2025
Last Update Date	:	03/21/2025

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Directions to “MY THERAPIST SHANNON LLC ” Practice Location

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