Provider Demographics
NPI:1205001153
Name:CALDE, SHANNON MAUREEN (56075)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MAUREEN
Last Name:CALDE
Suffix:
Gender:F
Credentials:56075
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 2075
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4460
Mailing Address - Country:US
Mailing Address - Phone:310-424-2090
Mailing Address - Fax:310-424-2096
Practice Address - Street 1:360 N SEPULVEDA BLVD
Practice Address - Street 2:SUITE 2075
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4460
Practice Address - Country:US
Practice Address - Phone:310-424-2090
Practice Address - Fax:310-424-2096
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56075106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist