Provider Demographics
NPI:1902865165
Name:PROUDFOOT, SHAWN (LISW)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:PROUDFOOT
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 MOON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3935
Mailing Address - Country:US
Mailing Address - Phone:505-271-0329
Mailing Address - Fax:505-271-4957
Practice Address - Street 1:1709 MOON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3935
Practice Address - Country:US
Practice Address - Phone:505-271-0329
Practice Address - Fax:505-271-4957
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490049821041C0700X
NMI-063691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL343172OtherTRICARE
ILL72547Medicare UPIN
IL373040Medicare ID - Type Unspecified