Basic Information
| Provider Information | |||||||||
| NPI: | 1083854806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULSIFER | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MFTI | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTS | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MFTI | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 31681 RIVERSIDE DR | ||||||||
| Address2: | SUITE L | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925307815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516749243 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 31681 RIVERSIDE DR | ||||||||
| Address2: | SUITE L | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925307815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516749243 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2009 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 58159 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.