Provider Demographics
NPI:1417685280
Name:LOUIS, SHAVONNE
Entity Type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:
Last Name:LOUIS
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 1:303 E. SOUTH MOUTAIN AVE
Mailing Address - Street 2:LOT 76
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042
Mailing Address - Country:US
Mailing Address - Phone:480-514-0288
Mailing Address - Fax:
Practice Address - Street 1:303 E. SOUTH MOUTAIN AVE
Practice Address - Street 2:LOT 76
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042
Practice Address - Country:US
Practice Address - Phone:480-514-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)