Healthcare Provider Details

I. General information

NPI: 1588380521
Provider Name (Legal Business Name): SHANE DAVIDO-DA SILVA LMSW-CC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 MINE HILL RD
FAIRFIELD CT
06824-2154
US

IV. Provider business mailing address

2950 MADISON AVE UNIT G
BRIDGEPORT CT
06606-2064
US

V. Phone/Fax

Practice location:
  • Phone: 844-217-6907
  • Fax:
Mailing address:
  • Phone: 203-767-5747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16443
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC24513
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: