Provider Demographics
NPI:1982391538
Name:WALDEN, SHANJAMARIE GENEVIE
Entity type:Individual
Prefix:
First Name:SHANJAMARIE
Middle Name:GENEVIE
Last Name:WALDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 LAKESIDE DR APT 232
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-7606
Mailing Address - Country:US
Mailing Address - Phone:954-275-0395
Mailing Address - Fax:
Practice Address - Street 1:422 LAKESIDE DR APT 232
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-7606
Practice Address - Country:US
Practice Address - Phone:954-275-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00000106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst