Healthcare Provider Details

I. General information

NPI: 1598233066
Provider Name (Legal Business Name): SHAVON LUMA MENTAL HEALTH THERAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date: 04/05/2019
Reactivation Date: 04/17/2019

III. Provider practice location address

304 NW 5TH ST
OKEECHOBEE FL
34972-2565
US

IV. Provider business mailing address

620 AMELIA CIR APT 8
BELLE GLADE FL
33430-6517
US

V. Phone/Fax

Practice location:
  • Phone: 561-914-4697
  • Fax:
Mailing address:
  • Phone: 561-914-4697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: