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General NPI Number Information
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NPI Number | 1861153447
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Entity Type | Individual
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Provider Name | SHADE ELIZABETH DE JESUS
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Gender | Female
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Dates
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Enumeration Date | 01/05/2022
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Last Update Date | 01/05/2022
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Provider Practice Location Address
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Address Line | 6750 N ANDREWS AVE STE 200
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City | FT LAUDERDALE
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State | FL
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Zip | 33309-2180
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Country | US
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Telephone | 954-758-8748
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Fax |
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Provider Business Mailing Address
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Address Line | 4200 INVERRARY BLVD APT 3807
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City | LAUDERHILL
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State | FL
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Zip | 33319-4136
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Country | US
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Telephone | 917-691-6891
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | D222785895450
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License Number State | FL
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