MEDICARE: MRS. LATONYA DENISE SHAW M.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker
2	101YM0800X	Mental Health Counselor	MH22407	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033419361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LATONYA DENISE SHAW M.S

Provider Business Mailing Address
First Line	:	PO BOX 881147
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34988-1147
Country	:	US
Telephone Number	:	561-294-5888
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 SEAFOAM CIR
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34945-1203
Country	:	US
Telephone Number	:	561-294-5888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2010
Last Update Date	:	08/02/2023

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