Healthcare Provider Details

I. General information

NPI: 1457729246
Provider Name (Legal Business Name): SHANELLE DAMASO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANELLE WALTERS

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 DEL PRADO BLVD S STE 200
CAPE CORAL FL
33904-5783
US

IV. Provider business mailing address

4310 METRO PKWY STE 205
FORT MYERS FL
33916-9416
US

V. Phone/Fax

Practice location:
  • Phone: 239-673-9034
  • Fax: 239-673-9102
Mailing address:
  • Phone: 239-236-8784
  • Fax: 239-790-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberW436-785-93-675-0
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW17394
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: