Provider Demographics
NPI:1124510011
Name:GAMMAGE, SHANE MATTHEW
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MATTHEW
Last Name:GAMMAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34406 N 27TH DR BLDG 6
Mailing Address - Street 2:SUITE 101-109
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6082
Mailing Address - Country:US
Mailing Address - Phone:562-400-6814
Mailing Address - Fax:
Practice Address - Street 1:34406 N 27TH DR BLDG 6
Practice Address - Street 2:SUITE 101-109
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6082
Practice Address - Country:US
Practice Address - Phone:480-863-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst