Provider Demographics
NPI:1831625540
Name:SUDDUTH, SHAWLEE
Entity type:Individual
Prefix:
First Name:SHAWLEE
Middle Name:
Last Name:SUDDUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FAIRFIELD
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-8029
Mailing Address - Country:US
Mailing Address - Phone:702-724-4238
Mailing Address - Fax:
Practice Address - Street 1:2215 N BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2663
Practice Address - Country:US
Practice Address - Phone:714-221-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health