Provider Demographics
NPI:1922640168
Name:SHAW, CARLO LAVERN
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:LAVERN
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5403 EUGENIA CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-3910
Mailing Address - Country:US
Mailing Address - Phone:407-276-2489
Mailing Address - Fax:
Practice Address - Street 1:6150 METRO WEST BLVD SUITE 103
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811
Practice Address - Country:US
Practice Address - Phone:407-276-2489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18808101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health