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NPI Code Detail

MEDICARE: VANESSA SHANTEL LIDGE

MEDICARE: VANESSA SHANTEL LIDGE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1891626701
Entity Type Code : Individual
Provider Name (Legal Business Name) : VANESSA SHANTEL LIDGE
Provider Business Mailing Address
First Line : 41920 N 45TH GLN
Second Line :
City : PHOENIX
State : AZ
Zip : 85086-1455
Country : US
Telephone Number : 716-367-8605
Fax Number :
Provider Business Practice Location Address
First Line : 41920 N 45TH GLN
Second Line :
City : PHOENIX
State : AZ
Zip : 85086-1455
Country : US
Telephone Number : 716-367-8605
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/28/2026
Last Update Date : 05/28/2026

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Directions to “ VANESSA SHANTEL LIDGE ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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