Provider Demographics
NPI:1043099633
Name:MOREAU, SHAE (LAC)
Entity Type:Individual
Prefix:
First Name:SHAE
Middle Name:
Last Name:MOREAU
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E MCKELLIPS RD APT 21A
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85288-1487
Mailing Address - Country:US
Mailing Address - Phone:512-762-6309
Mailing Address - Fax:
Practice Address - Street 1:1811 S ALMA SCHOOL RD STE 250
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3042
Practice Address - Country:US
Practice Address - Phone:512-762-6309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21693101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health