MEDICARE: SHANNON KELLY MCFAULS LMHC

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	17398	FL
2	101YM0800X	Mental Health Counselor	MH17398	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811231061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON KELLY MCFAULS LMHC

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	:	463380 STATE ROAD 200 UNIT B
Second Line	:
City	:	YULEE
State	:	FL
Zip	:	32097-3240
Country	:	US
Telephone Number	:	904-500-9808
Fax Number	:	904-432-0401

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

Provider Enumeration Date	:	11/11/2012
Last Update Date	:	10/21/2024

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