Provider Demographics
NPI:1033419361
Name:SHAW, LATONYA DENISE (MS)
Entity Type:Individual
Prefix:MRS
First Name:LATONYA
Middle Name:DENISE
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:LATONYA
Other - Middle Name:DENISE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 881147
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34988-1147
Mailing Address - Country:US
Mailing Address - Phone:561-294-5888
Mailing Address - Fax:
Practice Address - Street 1:405 SEAFOAM CIR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34945-1203
Practice Address - Country:US
Practice Address - Phone:561-294-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FLMH22407101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker