Basic Information
| Provider Information | |||||||||
| NPI: | 1306073952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERBERG | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WASHINGTON | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19231 VICTORY BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913356321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187084500 | ||||||||
| FaxNumber: | 8186541956 | ||||||||
| Practice Location | |||||||||
| Address1: | 19231 VICTORY BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913356321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187084500 | ||||||||
| FaxNumber: | 8186541956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC90568 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.