Provider Demographics
NPI:1235735390
Name:TERPSTRA, SHANE EDWIN
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:EDWIN
Last Name:TERPSTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8825 AERO DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2268
Mailing Address - Country:US
Mailing Address - Phone:858-633-4115
Mailing Address - Fax:
Practice Address - Street 1:8825 AERO DR STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2268
Practice Address - Country:US
Practice Address - Phone:858-633-4115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health