Provider Demographics
NPI:1295450617
Name:MCQUEEN, SHAVONNA TRAMAINE
Entity type:Individual
Prefix:
First Name:SHAVONNA
Middle Name:TRAMAINE
Last Name:MCQUEEN
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 1:608 S WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-4447
Mailing Address - Country:US
Mailing Address - Phone:863-873-1519
Mailing Address - Fax:
Practice Address - Street 1:608 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-4447
Practice Address - Country:US
Practice Address - Phone:863-873-1519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-238162106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBY22-238162OtherRBT