Healthcare Provider Details

I. General information

NPI: 1831625540
Provider Name (Legal Business Name): SHAWLEE SUDDUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 N BROADWAY SUITE 200
SANTA ANA CA
92706-2663
US

IV. Provider business mailing address

1 FAIRFIELD
ALISO VIEJO CA
92656-8029
US

V. Phone/Fax

Practice location:
  • Phone: 714-221-6400
  • Fax:
Mailing address:
  • Phone: 702-724-4238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: