Healthcare Provider Details

I. General information

NPI: 1174440648
Provider Name (Legal Business Name): SHIEATA WADE LACT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8335 W JEFFERSON ST
PEORIA AZ
85345-6516
US

IV. Provider business mailing address

8335 W JEFFERSON ST
PEORIA AZ
85345-6516
US

V. Phone/Fax

Practice location:
  • Phone: 602-621-6258
  • Fax:
Mailing address:
  • Phone: 602-621-6258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15220
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberLACT-15220
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: