Provider Demographics
NPI:1871615930
Name:REISER, SHAUNA LYNN (BA)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:LYNN
Last Name:REISER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 E CAMELBACK RD APT 287
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2651
Mailing Address - Country:US
Mailing Address - Phone:602-314-5398
Mailing Address - Fax:
Practice Address - Street 1:3819 E CAMELBACK RD APT 287
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2651
Practice Address - Country:US
Practice Address - Phone:602-314-5398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL4663235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ855794Medicaid