Provider Demographics
NPI:1649151812
Name:VAVANAM, SHAIK
Entity type:Individual
Prefix:MR
First Name:SHAIK
Middle Name:
Last Name:VAVANAM
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 1:4225 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-7475
Mailing Address - Country:US
Mailing Address - Phone:602-869-0785
Mailing Address - Fax:
Practice Address - Street 1:4225 E MCDOWELL RD
Practice Address - Street 2:APPT 2057
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7475
Practice Address - Country:US
Practice Address - Phone:602-869-0785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health