Provider Demographics
NPI:1164864807
Name:WALKER, SHANNON NICOLE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:WALKER
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 1:517 N MAIN ST STE 339
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4686
Mailing Address - Country:US
Mailing Address - Phone:714-732-2052
Mailing Address - Fax:
Practice Address - Street 1:517 N MAIN ST STE 339
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4686
Practice Address - Country:US
Practice Address - Phone:714-732-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA99183106H00000X
CAMFTI #75982106H00000X
CA34282103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist