Provider Demographics
NPI:1578073003
Name:WELLS, SHAWNA MARIE (RBT)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:MARIE
Last Name:WELLS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 GULF CIRCLE NORTH
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119
Mailing Address - Country:US
Mailing Address - Phone:501-358-1569
Mailing Address - Fax:
Practice Address - Street 1:500 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4504
Practice Address - Country:US
Practice Address - Phone:407-218-4340
Practice Address - Fax:407-218-4303
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019697600Medicaid