Provider Demographics
NPI:1447026513
Name:OWENS, SHAUNTAVIA GABRIELLE
Entity type:Individual
Prefix:
First Name:SHAUNTAVIA
Middle Name:GABRIELLE
Last Name:OWENS
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 1:605 BELL AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2310
Mailing Address - Country:US
Mailing Address - Phone:954-630-5731
Mailing Address - Fax:
Practice Address - Street 1:50 GENE CASH RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-4908
Practice Address - Country:US
Practice Address - Phone:270-465-7768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician