Provider Demographics
NPI:1679250104
Name:HOLLAND, SHAWANNA L
Entity Type:Individual
Prefix:
First Name:SHAWANNA
Middle Name:L
Last Name:HOLLAND
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 1:2901 W ANGEL WAY
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85144-6681
Mailing Address - Country:US
Mailing Address - Phone:520-213-1667
Mailing Address - Fax:
Practice Address - Street 1:908 W CHANDLER BLVD # A
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-2548
Practice Address - Country:US
Practice Address - Phone:480-899-0200
Practice Address - Fax:480-899-0202
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09-91152101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral