Provider Demographics
NPI:1144359985
Name:SAN PEDRO, SHANNON MARIE (MFTI#60844)
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:MARIE
Last Name:SAN PEDRO
Suffix:
Gender:F
Credentials:MFTI#60844
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFTI #60844
Mailing Address - Street 1:475 KENNERICK LN
Mailing Address - Street 2:UNIT B
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6781
Mailing Address - Country:US
Mailing Address - Phone:626-376-8809
Mailing Address - Fax:
Practice Address - Street 1:625 FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2630
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60844106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist