Healthcare Provider Details

I. General information

NPI: 1851583843
Provider Name (Legal Business Name): SHANNON GAMACHE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. SHANNON MACKAY

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 N CENTRAL AVE # A104
PHOENIX AZ
85012-1927
US

IV. Provider business mailing address

3636 N CENTRAL AVE
PHOENIX AZ
85012-1927
US

V. Phone/Fax

Practice location:
  • Phone: 808-489-8314
  • Fax:
Mailing address:
  • Phone: 480-848-9831
  • Fax: 602-241-5756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-18247
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: