Provider Demographics
NPI:1104380179
Name:GEORGE, SHAQWAN
Entity Type:Individual
Prefix:
First Name:SHAQWAN
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8073 MARSH CIR
Mailing Address - Street 2:
Mailing Address - City:LABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:33935-5468
Mailing Address - Country:US
Mailing Address - Phone:863-517-5186
Mailing Address - Fax:
Practice Address - Street 1:5245 RAMSEY WAY STE 5
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2124
Practice Address - Country:US
Practice Address - Phone:239-691-6482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty