Healthcare Provider Details

I. General information

NPI: 1578073003
Provider Name (Legal Business Name): SHAWNA MARIE WELLS RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLONIAL DR
ORLANDO FL
32803-4504
US

IV. Provider business mailing address

149 GULF CIRCLE NORTH
DAYTONA BEACH FL
32119
US

V. Phone/Fax

Practice location:
  • Phone: 407-218-4340
  • Fax: 407-218-4303
Mailing address:
  • Phone: 501-358-1569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: