Provider Demographics
NPI:1407257116
Name:SHEAK, ABBY
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:SHEAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1275
Mailing Address - Street 2:
Mailing Address - City:ALLYN
Mailing Address - State:WA
Mailing Address - Zip Code:98524-1275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 E NORTHCREST RD
Practice Address - Street 2:
Practice Address - City:ALLYN
Practice Address - State:WA
Practice Address - Zip Code:98524-8796
Practice Address - Country:US
Practice Address - Phone:360-801-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA274519866Medicaid