Provider Demographics
NPI:1083051544
Name:MINES, SHANTAY (EDS, LMFT)
Entity Type:Individual
Prefix:MR
First Name:SHANTAY
Middle Name:
Last Name:MINES
Suffix:
Gender:M
Credentials:EDS, LMFT
Other - Prefix:MR
Other - First Name:SHAWN
Other - Middle Name:
Other - Last Name:MINES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, EDS, LMFT
Mailing Address - Street 1:680 EPIC WAY APT 123
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-2836
Mailing Address - Country:US
Mailing Address - Phone:862-204-9364
Mailing Address - Fax:
Practice Address - Street 1:160 E VIRGINIA ST STE 100
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5865
Practice Address - Country:US
Practice Address - Phone:408-287-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124011106H00000X
FLIMT2104106H00000X
NCLMFTA #9001A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist