Healthcare Provider Details

I. General information

NPI: 1316854698
Provider Name (Legal Business Name): SIDRA N/A SHAFIQ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W HACKBERRY LN
ANNA TX
75409-2564
US

IV. Provider business mailing address

11353 LOBLOLLY WAY APT 10102
FRISCO TX
75035-3227
US

V. Phone/Fax

Practice location:
  • Phone: 847-612-9697
  • Fax: 847-612-9697
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: