Healthcare Provider Details

I. General information

NPI: 1023747169
Provider Name (Legal Business Name): SHADAN A SIRWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHADAN A FUQE

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 11/19/2023
Certification Date: 11/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7322 W RAWSON AVE
FRANKLIN WI
53132-8117
US

IV. Provider business mailing address

8560 W WATERFORD AVE APT 6
GREENFIELD WI
53228-2328
US

V. Phone/Fax

Practice location:
  • Phone: 414-292-4242
  • Fax: 262-240-9745
Mailing address:
  • Phone: 206-495-7614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11476-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: