Basic Information
| Provider Information | |||||||||
| NPI: | 1477812337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANE | ||||||||
| FirstName: | SABIAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 NORTH MAIN STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252866050 | ||||||||
| FaxNumber: | 9259376782 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 NORTH MAIN STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252866050 | ||||||||
| FaxNumber: | 9259376782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2012 | ||||||||
| LastUpdateDate: | 05/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.