Basic Information
| Provider Information | |||||||||
| NPI: | 1457729246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMASO | ||||||||
| FirstName: | SHANELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALTERS | ||||||||
| OtherFirstName: | SHANELLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4310 METRO PKWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392368784 | ||||||||
| FaxNumber: | 2397902624 | ||||||||
| Practice Location | |||||||||
| Address1: | 2721 DEL PRADO BLVD S STE 200 | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339045783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396739034 | ||||||||
| FaxNumber: | 2396739102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2015 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | W436-785-93-675-0 | FL | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | SW17394 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.