Provider Demographics
NPI:1053680843
Name:SHIMABUKURO, JOANN LEE (PSYD, MA, MS)
Entity Type:Individual
Prefix:DR
First Name:JOANN
Middle Name:LEE
Last Name:SHIMABUKURO
Suffix:
Gender:F
Credentials:PSYD, MA, MS
Other - Prefix:MS
Other - First Name:JOANN
Other - Middle Name:LEE
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:7219 N LITCHFIELD RD
Mailing Address - Street 2:56 MEDICAL GROUP
Mailing Address - City:LUKE AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85309-1529
Mailing Address - Country:US
Mailing Address - Phone:623-856-7579
Mailing Address - Fax:623-856-4433
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:56 MEDICAL GROUP
Practice Address - City:LUKE AFB
Practice Address - State:AZ
Practice Address - Zip Code:85309-1529
Practice Address - Country:US
Practice Address - Phone:623-856-7579
Practice Address - Fax:623-856-4433
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY1298103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth