Basic Information
| Provider Information | |||||||||
| NPI: | 1720714694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CODY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
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| OtherLastName: | HOFMANN | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 490 N GRAPE ST | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609759939 | ||||||||
| FaxNumber: | 7605099093 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 N GRAPE ST | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609759939 | ||||||||
| FaxNumber: | 7605099093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2022 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.