Provider Demographics
NPI:1265503544
Name:SHISSLAK, CATHERINE M (PHD)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:M
Last Name:SHISSLAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 E ELVIRA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706-7124
Mailing Address - Country:US
Mailing Address - Phone:520-874-3500
Mailing Address - Fax:520-874-3425
Practice Address - Street 1:707 N ALVERNON WAY STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-0001
Practice Address - Country:US
Practice Address - Phone:520-694-8888
Practice Address - Fax:520-694-1640
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ878103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ730798Medicaid
R90172Medicare UPIN
AZ730798Medicaid