Provider Demographics
NPI:1124505045
Name:LIDDELL, SHANA MORGAN
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:MORGAN
Last Name:LIDDELL
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 1:8572 E INDIAN SCHOOL RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-4943
Mailing Address - Country:US
Mailing Address - Phone:847-302-7042
Mailing Address - Fax:
Practice Address - Street 1:483 W SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147
Practice Address - Country:US
Practice Address - Phone:520-562-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-17024101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor