Basic Information
Provider Information | |||||||||
NPI: | 1891930228 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANSON | ||||||||
FirstName: | SHIRLEY | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEON | ||||||||
OtherFirstName: | SHIRLEY | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3003 N CENTRAL AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850122902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026856000 | ||||||||
FaxNumber: | 6026856001 | ||||||||
Practice Location | |||||||||
Address1: | 1415 N 1ST ST | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 85004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026856000 | ||||||||
FaxNumber: | 6026856001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2008 | ||||||||
LastUpdateDate: | 07/13/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW-12619 | AZ | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | LCSW-16581 | AZ | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 341664 | 05 | AZ |   | MEDICAID |