Provider Demographics
NPI:1225118144
Name:SHIPMAN, CYNTHIA JANE I (PHD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:JANE
Last Name:SHIPMAN
Suffix:I
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5575 LAKE PARK WAY
Mailing Address - Street 2:114
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1664
Mailing Address - Country:US
Mailing Address - Phone:619-463-1155
Mailing Address - Fax:619-463-8986
Practice Address - Street 1:5575 LAKE PARK WAY
Practice Address - Street 2:114
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-1664
Practice Address - Country:US
Practice Address - Phone:619-463-1155
Practice Address - Fax:619-463-8986
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5863103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY058630Medicaid
CAPSY058630Medicaid