Basic Information
Provider Information | |||||||||
NPI: | 1962679555 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEARER | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4202 E CACTUS RD APT 1310 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850327662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5205623321 | ||||||||
FaxNumber: | 6025281374 | ||||||||
Practice Location | |||||||||
Address1: | 483 SEED FARM ROAD | ||||||||
Address2: | HU HU KAM MEMORIAL HOSPITAL | ||||||||
City: | SACATON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5205623321 | ||||||||
FaxNumber: | 6025281374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2008 | ||||||||
LastUpdateDate: | 05/13/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW-12455 | AZ | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 346214 | 05 | AZ |   | MEDICAID |