Provider Demographics
NPI:1437642329
Name:SHUMWAY, GRETA (MC, LAC)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:SHUMWAY
Suffix:
Gender:F
Credentials:MC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 E. WARNER ROAD
Mailing Address - Street 2:#115
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296
Mailing Address - Country:US
Mailing Address - Phone:480-444-2434
Mailing Address - Fax:480-588-8454
Practice Address - Street 1:690 E. WARNER ROAD
Practice Address - Street 2:#115
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296
Practice Address - Country:US
Practice Address - Phone:480-444-2434
Practice Address - Fax:480-588-8454
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health