Provider Demographics
NPI:1225602311
Name:MARKOVICH, SHANNON LYNN (CASAC, LSAT, CADAC,)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:LYNN
Last Name:MARKOVICH
Suffix:
Gender:F
Credentials:CASAC, LSAT, CADAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 N NORWALK STE 103
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1148
Mailing Address - Country:US
Mailing Address - Phone:480-597-5699
Mailing Address - Fax:
Practice Address - Street 1:2812 N NORWALK STE 103
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-1148
Practice Address - Country:US
Practice Address - Phone:480-597-5699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3088101YA0400X
NY20104101YA0400X
AZLSAT-15151101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)