Provider Demographics
NPI:1124327747
Name:SHEA, MECHELLE LYNETTE
Entity type:Individual
Prefix:
First Name:MECHELLE
Middle Name:LYNETTE
Last Name:SHEA
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 1:2805 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-2715
Mailing Address - Country:US
Mailing Address - Phone:830-391-5454
Mailing Address - Fax:
Practice Address - Street 1:2805 E 9TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2715
Practice Address - Country:US
Practice Address - Phone:830-391-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2397966385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child