Basic Information
| Provider Information | |||||||||
| NPI: | 1447567789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARLSON | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1211 EMBARCADERO | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946065119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105351409 | ||||||||
| FaxNumber: | 5105351414 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 EMBARCADERO | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946065119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105351409 | ||||||||
| FaxNumber: | 5105351414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2010 | ||||||||
| LastUpdateDate: | 09/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.