Basic Information
| Provider Information | |||||||||
| NPI: | 1114070240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEIN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5000 | ||||||||
| Address2: | |||||||||
| City: | COALINGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932105000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599354300 | ||||||||
| FaxNumber: | 5599354308 | ||||||||
| Practice Location | |||||||||
| Address1: | 24511 WEST JAYNE AVENUE | ||||||||
| Address2: | |||||||||
| City: | COALINGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599354300 | ||||||||
| FaxNumber: | 5599354308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2007 | ||||||||
| LastUpdateDate: | 10/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY11865 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0200X | PSY11865 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Forensic |
ID Information
| ID | Type | State | Issuer | Description | PSY118650 | 05 | CA | MEDICAID |