Basic Information
| Provider Information | |||||||||
| NPI: | 1881876654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYHALL | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15095 AMARGOSA RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923941879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602454695 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14360 SAINT ANDREWS DR | ||||||||
| Address2: | STE 11 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923954341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602454695 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2007 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
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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 | 106H00000X | 55523 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.