MEDICARE: SHANTAVIA R BIVENS

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1427975515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTAVIA R BIVENS

Provider Business Mailing Address
First Line	:	330 AQUARIUS CONCOURSE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-2434
Country	:	US
Telephone Number	:	904-250-1190
Fax Number	:

Provider Business Practice Location Address
First Line	:	2377 MARKET DR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-4326
Country	:	US
Telephone Number	:	904-579-4779
Fax Number	:

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

Provider Enumeration Date	:	06/30/2026
Last Update Date	:	06/30/2026

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Directions to “ SHANTAVIA R BIVENS ” Practice Location

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