Provider Demographics
NPI:1972020428
Name:FARMER, SHAWAVIAN A
Entity Type:Individual
Prefix:
First Name:SHAWAVIAN
Middle Name:A
Last Name:FARMER
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 1:17637 CALLE DE AMIGOS
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-6351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17637 CALLE DE AMIGOS
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-6351
Practice Address - Country:US
Practice Address - Phone:951-543-7438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA98573138F65012OtherIEHP