Provider Demographics
NPI:1871110528
Name:PATEL, SHIVAM U
Entity type:Individual
Prefix:
First Name:SHIVAM
Middle Name:U
Last Name:PATEL
Suffix:
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 1:1700 HOOKS ST UNIT 3201
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3577
Mailing Address - Country:US
Mailing Address - Phone:630-608-3709
Mailing Address - Fax:
Practice Address - Street 1:644 FERGUSON DR STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1023
Practice Address - Country:US
Practice Address - Phone:407-574-4629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician