Healthcare Provider Details

I. General information

NPI: 1386714764
Provider Name (Legal Business Name): SHAWN P EMMONS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 11/15/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 E MISSOURI AVE STE B275
PHOENIX AZ
85014-2490
US

IV. Provider business mailing address

1430 E MISSOURI AVE STE B275
PHOENIX AZ
85014-2490
US

V. Phone/Fax

Practice location:
  • Phone: 480-204-1568
  • Fax:
Mailing address:
  • Phone: 480-204-1568
  • Fax: 703-670-8213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003640
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: