Provider Demographics
NPI:1588481030
Name:SHEA PEDIATRIC PSYCHIATRY PLLC
Entity type:Organization
Organization Name:SHEA PEDIATRIC PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NADIA
Authorized Official - Middle Name:GEORGINA
Authorized Official - Last Name:LEDESMA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C, PMHNP-B
Authorized Official - Phone:602-218-1240
Mailing Address - Street 1:3509 E SHEA BLVD STE 117Q
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3336
Mailing Address - Country:US
Mailing Address - Phone:602-218-1240
Mailing Address - Fax:
Practice Address - Street 1:3509 E SHEA BLVD STE 117Q
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3336
Practice Address - Country:US
Practice Address - Phone:602-218-1240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-25
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty