=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093425985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON MARIE BALABAN PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2022
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9327 N 3RD ST STE 200
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85020-2473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-595-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9327 N 3RD ST STE 200
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85020-2473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-595-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY-005745
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------