Provider Demographics
NPI:1801302112
Name:SHABAZZ, DAVENA (MSW, CBHCMS)
Entity type:Individual
Prefix:
First Name:DAVENA
Middle Name:
Last Name:SHABAZZ
Suffix:
Gender:F
Credentials:MSW, CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 SAINT AUGUSTINE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7140
Mailing Address - Country:US
Mailing Address - Phone:407-844-9676
Mailing Address - Fax:
Practice Address - Street 1:2860 SAINT AUGUSTINE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-7140
Practice Address - Country:US
Practice Address - Phone:407-470-3630
Practice Address - Fax:407-270-5935
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2022-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCCM101450-A171M00000X
FLCBHCMS.0102557171M00000X
FLISW121731041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker