Provider Demographics
NPI:1184027096
Name:SWANSTON, SHANNON (IMF 82675)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SWANSTON
Suffix:
Gender:F
Credentials:IMF 82675
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:OBERST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 WALNUT AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3900
Mailing Address - Country:US
Mailing Address - Phone:831-423-9444
Mailing Address - Fax:831-423-1532
Practice Address - Street 1:104 WALNUT AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3900
Practice Address - Country:US
Practice Address - Phone:831-423-9444
Practice Address - Fax:831-423-1532
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 82675101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF 82675OtherCOUNSELING