Basic Information
| Provider Information | |||||||||
| NPI: | 1487377784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 WINDY PASS SPC 154 | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923115476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4424558822 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16248 VICTOR ST | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923953934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602437151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2022 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | B3727585 | 01 | CA | SUBSTANCE USE DISORDER | OTHER |