Provider Demographics
NPI:1760154678
Name:MCKISSICK, SHANA L (MA, LAC)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:L
Last Name:MCKISSICK
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 N KENNETH PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2944
Mailing Address - Country:US
Mailing Address - Phone:480-309-9335
Mailing Address - Fax:
Practice Address - Street 1:16815 S DESERT FOOTHILLS PKWY STE 134
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-8465
Practice Address - Country:US
Practice Address - Phone:602-550-5221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC20269101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health