Provider Demographics
NPI:1821431073
Name:CORMICK, SHAVON DONASINA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SHAVON
Middle Name:DONASINA
Last Name:CORMICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1558
Mailing Address - Country:US
Mailing Address - Phone:817-255-7153
Mailing Address - Fax:
Practice Address - Street 1:101 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-1558
Practice Address - Country:US
Practice Address - Phone:817-255-7153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52367104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker