Healthcare Provider Details

I. General information

NPI: 1184546483
Provider Name (Legal Business Name): SHAWN ALEXANDER MONTILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17235 N 75TH AVE
GLENDALE AZ
85308-0831
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

V. Phone/Fax

Practice location:
  • Phone: 480-812-4789
  • Fax:
Mailing address:
  • Phone: 866-610-0580
  • Fax: 866-611-1558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-437915
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: