Provider Demographics
NPI:1528614864
Name:MERIDETH, SHAUNA
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:MERIDETH
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 1:3085 S ST MIHIEL CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-0282
Mailing Address - Country:US
Mailing Address - Phone:907-841-3269
Mailing Address - Fax:
Practice Address - Street 1:3085 S ST MIHIEL CIR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-0282
Practice Address - Country:US
Practice Address - Phone:907-841-3269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
AK517612106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician