Provider Demographics
NPI:1477686533
Name:FRESHWATER, SHAWNA MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHAWNA
Middle Name:MARIE
Last Name:FRESHWATER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BRICKELL AVE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33131-2951
Mailing Address - Country:US
Mailing Address - Phone:305-632-9902
Mailing Address - Fax:305-371-4447
Practice Address - Street 1:801 BRICKELL AVE
Practice Address - Street 2:SUITE 900
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-2951
Practice Address - Country:US
Practice Address - Phone:305-632-9902
Practice Address - Fax:305-371-4447
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6446103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54873ZMedicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST