Basic Information
Provider Information | |||||||||
NPI: | 1386009504 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COURTNEY | ||||||||
FirstName: | SHANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1433 E ROUTE 66 STE F | ||||||||
Address2: |   | ||||||||
City: | GLENDORA | ||||||||
State: | CA | ||||||||
PostalCode: | 917403747 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269630004 | ||||||||
FaxNumber: | 6269630036 | ||||||||
Practice Location | |||||||||
Address1: | 23701 E EAST FORK RD | ||||||||
Address2: |   | ||||||||
City: | AZUSA | ||||||||
State: | CA | ||||||||
PostalCode: | 917021477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262503290 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2015 | ||||||||
LastUpdateDate: | 03/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.