Provider Demographics
NPI:1225539216
Name:STEVENSON SMITH, SHAWNDRIKA
Entity Type:Individual
Prefix:MS
First Name:SHAWNDRIKA
Middle Name:
Last Name:STEVENSON SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2494 RAVENALL AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-5540
Mailing Address - Country:US
Mailing Address - Phone:407-289-6886
Mailing Address - Fax:
Practice Address - Street 1:148 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5372
Practice Address - Country:US
Practice Address - Phone:321-972-4039
Practice Address - Fax:321-445-9760
Is Sole Proprietor?:No
Enumeration Date:2018-02-24
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-70349106S00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLATN702346Medicaid
FL023918100Medicaid