Healthcare Provider Details

I. General information

NPI: 1528997707
Provider Name (Legal Business Name): SHAVON CALIN NATHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 GRAHAM CIR
LEHIGH ACRES FL
33936-1110
US

IV. Provider business mailing address

3260 STOCKTON ST APT 315
FORT MYERS FL
33903-1622
US

V. Phone/Fax

Practice location:
  • Phone: 305-390-2369
  • Fax:
Mailing address:
  • Phone: 754-272-1669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberRBT-26-536863
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: