Provider Demographics
NPI:1972661072
Name:BUCKLIN HARVEY, SHANNON MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MICHELLE
Last Name:BUCKLIN HARVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:MICHELLE
Other - Last Name:BUCKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4072 E 22ND ST
Mailing Address - Street 2:PMB 313
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706
Mailing Address - Country:US
Mailing Address - Phone:520-574-0197
Mailing Address - Fax:
Practice Address - Street 1:10859 S SWAN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746
Practice Address - Country:US
Practice Address - Phone:520-574-0197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9218385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child