Healthcare Provider Details

I. General information

NPI: 1245090711
Provider Name (Legal Business Name): SHANTERE BUZE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 S DEW DROP LN
GILBERT AZ
85297-8031
US

IV. Provider business mailing address

3875 S DEW DROP LN
GILBERT AZ
85297-8031
US

V. Phone/Fax

Practice location:
  • Phone: 716-491-3647
  • Fax:
Mailing address:
  • Phone: 716-491-3647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC15601
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: