Provider Demographics
NPI:1700103710
Name:FASSETT, SHELLEY ANNE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:SHELLEY
Middle Name:ANNE
Last Name:FASSETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:ANNE
Other - Last Name:JANSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 N CENTENNIAL WAY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-6702
Mailing Address - Country:US
Mailing Address - Phone:602-290-0278
Mailing Address - Fax:
Practice Address - Street 1:245 N CENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:602-290-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW171271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ373998Medicaid