Provider Demographics
NPI:1669240248
Name:OLDRIDGE, SHAUN EDGAR (LASAC)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:EDGAR
Last Name:OLDRIDGE
Suffix:
Gender:M
Credentials:LASAC
Other - Prefix:
Other - First Name:SHAUN
Other - Middle Name:EDGAR
Other - Last Name:OLDRIDGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2102 W BETHANY HOME RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1935
Mailing Address - Country:US
Mailing Address - Phone:027-744-4745
Mailing Address - Fax:
Practice Address - Street 1:2102 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1935
Practice Address - Country:US
Practice Address - Phone:480-208-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ08007T101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)