Provider Demographics
NPI:1023747169
Name:SIRWAN, SHADAN A
Entity type:Individual
Prefix:
First Name:SHADAN
Middle Name:A
Last Name:SIRWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHADAN
Other - Middle Name:A
Other - Last Name:FUQE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8560 W WATERFORD AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2328
Mailing Address - Country:US
Mailing Address - Phone:206-495-7614
Mailing Address - Fax:
Practice Address - Street 1:7322 W RAWSON AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8117
Practice Address - Country:US
Practice Address - Phone:414-292-4242
Practice Address - Fax:262-240-9745
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
WI11476-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional