Provider Demographics
NPI:1114051679
Name:MICHELSON, SHANNON BARBARA
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:BARBARA
Last Name:MICHELSON
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:PO BOX 5956
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95150-5956
Mailing Address - Country:US
Mailing Address - Phone:408-972-3419
Mailing Address - Fax:
Practice Address - Street 1:5755 COTTLE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3640
Practice Address - Country:US
Practice Address - Phone:408-972-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS212471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical