Provider Demographics
NPI:1821972290
Name:WATSON, SHASNOR SR
Entity type:Individual
Prefix:
First Name:SHASNOR
Middle Name:
Last Name:WATSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3176 BAYOU LN
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-2060
Mailing Address - Country:US
Mailing Address - Phone:352-800-1804
Mailing Address - Fax:
Practice Address - Street 1:3176 BAYOU LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-2060
Practice Address - Country:US
Practice Address - Phone:352-800-1804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB674148106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty