MEDICARE: SHAVONTAE R EASON

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	175T00000X	Peer Specialist	FPS.000138	OH
2	175T00000X	Peer Specialist	APS.004857	OH

General Provider Information

NPI Number	:	1669228482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAVONTAE R EASON

Provider Business Mailing Address
First Line	:	443 RICHMOND PARK W APT 617D
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	OH
Zip	:	44143-1895
Country	:	US
Telephone Number	:	216-256-9869
Fax Number	:

Provider Business Practice Location Address
First Line	:	443 RICHMOND PARK W APT 617D
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	OH
Zip	:	44143-1895
Country	:	US
Telephone Number	:	216-256-9869
Fax Number	:

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

Provider Enumeration Date	:	04/24/2024
Last Update Date	:	04/24/2024

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Directions to “ SHAVONTAE R EASON ” Practice Location

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