Provider Demographics
NPI:1801397732
Name:WOFFORD, SHAYNA MELLISSA
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:MELLISSA
Last Name:WOFFORD
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 1:21505 N 78TH AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3356
Mailing Address - Country:US
Mailing Address - Phone:623-204-4703
Mailing Address - Fax:
Practice Address - Street 1:21505 N 78TH AVE STE 125
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3356
Practice Address - Country:US
Practice Address - Phone:623-204-4703
Practice Address - Fax:623-204-4703
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-17-36918106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$OtherSOCIAL SECURITY