Provider Demographics
NPI:1316768492
Name:LAFORM O'SHEA, COLLEEN (RBT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:LAFORM O'SHEA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:185-583-2672
Mailing Address - Fax:
Practice Address - Street 1:1229 38TH AVE N # 391
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1313
Practice Address - Country:US
Practice Address - Phone:185-583-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-22-235761106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician