Basic Information
| Provider Information | |||||||||
| NPI: | 1740649250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | VIVIENNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RADT-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5870 ARLINGTON AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836596 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5870 ARLINGTON AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836596 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2016 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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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 | 1740649250 | 01 | CA | MEDI-CAL | OTHER |