Healthcare Provider Details

I. General information

NPI: 1053680843
Provider Name (Legal Business Name): JOANN LEE SHIMABUKURO PSY.D., M.A., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOANN LEE GRAHAM N/A

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 N LITCHFIELD RD 56 MEDICAL GROUP
LUKE AFB AZ
85309-1529
US

IV. Provider business mailing address

7219 N LITCHFIELD RD 56 MEDICAL GROUP
LUKE AFB AZ
85309-1529
US

V. Phone/Fax

Practice location:
  • Phone: 623-856-7579
  • Fax: 623-856-4433
Mailing address:
  • Phone: 623-856-7579
  • Fax: 623-856-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1298
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY1298
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: