Provider Demographics
NPI:1154339109
Name:BRODALA, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRODALA
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 1:8253 W THUNDERBIRD RD
Mailing Address - Street 2:#103
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8253 W THUNDERBIRD RD
Practice Address - Street 2:#103
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4616
Practice Address - Country:US
Practice Address - Phone:623-826-0932
Practice Address - Fax:623-776-9921
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1457349037101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health