Provider Demographics
NPI:1962886184
Name:VARGHESE, SHIJU (LMFT)
Entity type:Individual
Prefix:
First Name:SHIJU
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 COUNTRY COTTAGE LN
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-6544
Mailing Address - Country:US
Mailing Address - Phone:973-229-3503
Mailing Address - Fax:
Practice Address - Street 1:3125 BRUTON BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-6608
Practice Address - Country:US
Practice Address - Phone:407-514-4563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3192.106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist