Provider Demographics
NPI:1194889758
Name:SHINN, ERIC R (MC)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:R
Last Name:SHINN
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18115 E BELLERIVE DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-8419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1232 E. BROADWAY RD SUIT #120
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-784-1514
Practice Address - Fax:480-967-3528
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-10282101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ614356Medicaid