Provider Demographics
NPI:1366092306
Name:ROEN, SHAWNA (LCSW)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:ROEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 E DESERT DR
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-8802
Mailing Address - Country:US
Mailing Address - Phone:928-862-8689
Mailing Address - Fax:
Practice Address - Street 1:3640 HIGHWAY 95 STE 120
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-4336
Practice Address - Country:US
Practice Address - Phone:928-900-4748
Practice Address - Fax:928-420-8950
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LCSW-19912101YM0800X
AZ191121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health