Provider Demographics
NPI:1013650670
Name:HEAVILIN, SHAUN D (HIS)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:D
Last Name:HEAVILIN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-3007
Mailing Address - Country:US
Mailing Address - Phone:386-846-8520
Mailing Address - Fax:
Practice Address - Street 1:4626 CLYDE MORRIS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6402
Practice Address - Country:US
Practice Address - Phone:386-492-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5613237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist