Provider Demographics
NPI:1861153447
Name:DE JESUS, SHADE ELIZABETH
Entity type:Individual
Prefix:
First Name:SHADE
Middle Name:ELIZABETH
Last Name:DE JESUS
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 1:4200 INVERRARY BLVD APT 3807
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4136
Mailing Address - Country:US
Mailing Address - Phone:917-691-6891
Mailing Address - Fax:
Practice Address - Street 1:6750 N ANDREWS AVE STE 200
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2180
Practice Address - Country:US
Practice Address - Phone:954-758-8748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD222785895450106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician