1124980800 NPI number — SHAPE SPACE BEHAVIORAL SOLUTIONS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124980800 NPI number — SHAPE SPACE BEHAVIORAL SOLUTIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHAPE SPACE BEHAVIORAL SOLUTIONS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124980800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 SANDPIPER PT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEPTUNE BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32266-1526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-910-7393
Provider Business Mailing Address Fax Number:
904-910-7393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 SANDPIPER PT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEPTUNE BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32266-1526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-910-7393
Provider Business Practice Location Address Fax Number:
904-910-7393
Provider Enumeration Date:
12/01/2025

Additional Information

Authorized Official

Authorized Official Last Name:
NOWELL
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
BEACH
Authorized Official Title or Position:
BCBA/OWNER
Authorized Official Telephone Number:
904-910-7393

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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