Healthcare Provider Details

I. General information

NPI: 1164355277
Provider Name (Legal Business Name): STEPHANIE SHUDAREK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 S ALMA SCHOOL RD STE 104
MESA AZ
85210-3086
US

IV. Provider business mailing address

1174 N LARAT LN
COOLIDGE AZ
85128-1006
US

V. Phone/Fax

Practice location:
  • Phone: 602-529-1967
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-22978
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: