Provider Demographics
NPI:1881320828
Name:NICHOLS, SHANNON (RMHCI, RMFT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RMHCI, RMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4503
Mailing Address - Country:US
Mailing Address - Phone:321-356-1478
Mailing Address - Fax:
Practice Address - Street 1:11315 CORPORATE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8340
Practice Address - Country:US
Practice Address - Phone:407-534-0186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-30
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22695101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health