Healthcare Provider Details

I. General information

NPI: 1215535349
Provider Name (Legal Business Name): MATAVIOUS SHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6961 UNIVERSITY BLVD
WINTER PARK FL
32792-6710
US

IV. Provider business mailing address

4450 MEDALLION DR APT 906
ORLANDO FL
32808-1334
US

V. Phone/Fax

Practice location:
  • Phone: 407-543-8356
  • Fax:
Mailing address:
  • Phone: 321-800-1517
  • 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: