1629510169 NPI number — DR. SHANNON LEAH HENDRICKSON PSY.D.

Table of content: DR. SHANNON LEAH HENDRICKSON PSY.D. (NPI 1629510169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629510169 NPI number — DR. SHANNON LEAH HENDRICKSON PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKSON
Provider First Name:
SHANNON
Provider Middle Name:
LEAH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629510169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15411 W WADDELL RD, STE 102
Provider Second Line Business Mailing Address:
#1096
Provider Business Mailing Address City Name:
SURPRISE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-492-2995
Provider Business Mailing Address Fax Number:
623-288-8017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15411 W WADDELL RD, STE 102
Provider Second Line Business Practice Location Address:
#1096
Provider Business Practice Location Address City Name:
SURPRISE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-492-2995
Provider Business Practice Location Address Fax Number:
623-288-8017
Provider Enumeration Date:
11/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  4779 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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