Provider Demographics
NPI:1043803232
Name:HARRIS, SHANTELL
Entity Type:Individual
Prefix:MS
First Name:SHANTELL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 W MAXZIM AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-3149
Mailing Address - Country:US
Mailing Address - Phone:714-718-6363
Mailing Address - Fax:
Practice Address - Street 1:1568 MCLEOD PL
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-1348
Practice Address - Country:US
Practice Address - Phone:909-620-7543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical