Provider Demographics
NPI:1922695352
Name:KIRKWOOD, SHANNETTE
Entity Type:Individual
Prefix:MS
First Name:SHANNETTE
Middle Name:
Last Name:KIRKWOOD
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 1:12242 N 48TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-2207
Mailing Address - Country:US
Mailing Address - Phone:219-512-4679
Mailing Address - Fax:
Practice Address - Street 1:12242 N 48TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-2207
Practice Address - Country:US
Practice Address - Phone:219-512-4679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10782736103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst