Healthcare Provider Details

I. General information

NPI: 1023185410
Provider Name (Legal Business Name): ERIK RAY SHAFFER BS LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 E BROADWAY RD 120
TEMPE AZ
85282-1511
US

IV. Provider business mailing address

274 E LAREDO AVE
GILBERT AZ
85296-1650
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-1514
  • Fax: 480-967-3528
Mailing address:
  • Phone: 480-733-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10156
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: