Basic Information
| Provider Information | |||||||||
| NPI: | 1902865165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROUDFOOT | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1709 MOON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871123935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052710329 | ||||||||
| FaxNumber: | 5052714957 | ||||||||
| Practice Location | |||||||||
| Address1: | 1709 MOON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871123935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052710329 | ||||||||
| FaxNumber: | 5052714957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 08/25/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149004982 | IL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | I-06369 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 343172 | 01 | IL | TRICARE | OTHER |