Provider Demographics
NPI:1023185410
Name:SHAFFER, ERIK RAY (BS LISAC)
Entity Type:Individual
Prefix:MR
First Name:ERIK
Middle Name:RAY
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:BS LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 E LAREDO AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1650
Mailing Address - Country:US
Mailing Address - Phone:480-733-6992
Mailing Address - Fax:
Practice Address - Street 1:1232 E BROADWAY RD
Practice Address - Street 2:120
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1511
Practice Address - Country:US
Practice Address - Phone:480-784-1514
Practice Address - Fax:480-967-3528
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10156101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)