Provider Demographics
NPI:1881727444
Name:SEYEDAN, SHANNON L (LCSW, LISAC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:SEYEDAN
Suffix:
Gender:F
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 1:2722 S 186TH DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4216
Mailing Address - Country:US
Mailing Address - Phone:480-650-6242
Mailing Address - Fax:
Practice Address - Street 1:2722 S 186TH DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4216
Practice Address - Country:US
Practice Address - Phone:480-650-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10312101YA0400X
AZLCSW-105731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ761412OtherPROVIDER NUMBER