Provider Demographics
NPI:1568922144
Name:DASH, SHAVONNE
Entity Type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:
Last Name:DASH
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 1:70 OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-8904
Mailing Address - Country:US
Mailing Address - Phone:203-380-8060
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker