Provider Demographics
NPI:1417281296
Name:STICKEN, SHANNON M (PSYD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:STICKEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 N SWAN RD STE 200-3
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4042
Mailing Address - Country:US
Mailing Address - Phone:520-326-5761
Mailing Address - Fax:
Practice Address - Street 1:1661 N SWAN RD STE 200-3
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4042
Practice Address - Country:US
Practice Address - Phone:520-326-5761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
AZ4233103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor