Basic Information
| Provider Information | |||||||||
| NPI: | 1972626521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | SHAFFER | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12851 HASTER ST APT 11D | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928406560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143499063 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4000 W METROPOLITAN DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668306011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 98637 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.