Provider Demographics
NPI:1104609593
Name:ELKINS, SHAVAUGHN E (MSRLS-CTRS)
Entity type:Individual
Prefix:
First Name:SHAVAUGHN
Middle Name:E
Last Name:ELKINS
Suffix:
Gender:F
Credentials:MSRLS-CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19456 W WOODLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-5886
Mailing Address - Country:US
Mailing Address - Phone:254-462-4133
Mailing Address - Fax:
Practice Address - Street 1:650 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist