Provider Demographics
NPI:1679089189
Name:TREMOULIS, SHAWNA (MS, LASAC)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:TREMOULIS
Suffix:
Gender:F
Credentials:MS, LASAC
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 1114
Mailing Address - Street 2:
Mailing Address - City:EAGAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85925-1114
Mailing Address - Country:US
Mailing Address - Phone:602-796-3970
Mailing Address - Fax:
Practice Address - Street 1:3100 W RAY RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2470
Practice Address - Country:US
Practice Address - Phone:480-418-1696
Practice Address - Fax:602-569-4328
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
AZLASAC-15445101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician