Provider Demographics
NPI:1396887402
Name:SHANLEY, MICHAEL N (LCSW, LISAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:N
Last Name:SHANLEY
Suffix:
Gender:M
Credentials:LCSW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9405 S AVENIDA DEL YAQUI
Mailing Address - Street 2:
Mailing Address - City:GUADALUPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-2529
Mailing Address - Country:US
Mailing Address - Phone:480-768-2026
Mailing Address - Fax:480-768-2053
Practice Address - Street 1:9405 S AVENIDA DEL YAQUI
Practice Address - Street 2:
Practice Address - City:GUADALUPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2529
Practice Address - Country:US
Practice Address - Phone:480-768-2026
Practice Address - Fax:480-768-2053
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10254101YA0400X
AZLCSW-104611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ854580Medicaid