Provider Demographics
NPI:1235505041
Name:IGE, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:IGE
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 1:15339 SATICOY ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3345
Mailing Address - Country:US
Mailing Address - Phone:818-267-2646
Mailing Address - Fax:
Practice Address - Street 1:15339 SATICOY ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3345
Practice Address - Country:US
Practice Address - Phone:818-267-2646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-16
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF2401027390200000X
CA78002101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program