Provider Demographics
NPI:1083747588
Name:SHANNON, NICOLE BONASSI (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:BONASSI
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 HOPE ST
Mailing Address - Street 2:#305
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2628
Mailing Address - Country:US
Mailing Address - Phone:626-644-4355
Mailing Address - Fax:
Practice Address - Street 1:1605 HOPE ST
Practice Address - Street 2:#305
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2628
Practice Address - Country:US
Practice Address - Phone:626-644-4355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS21044104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker