Provider Demographics
NPI:1861905986
Name:NORTH, SHAWN MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:SHAWN
Middle Name:MARIE
Last Name:NORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:MARIE
Other - Last Name:PENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1219 MILLENNIUM PKWY STE 116
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-3891
Mailing Address - Country:US
Mailing Address - Phone:630-391-2035
Mailing Address - Fax:
Practice Address - Street 1:1219 MILLENNIUM PKWY
Practice Address - Street 2:STE 116
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-3891
Practice Address - Country:US
Practice Address - Phone:630-391-2035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW140611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020425900Medicaid