Provider Demographics
NPI:1275995979
Name:SHIN, IIHAE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:IIHAE
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 N GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3515
Mailing Address - Country:US
Mailing Address - Phone:626-394-6040
Mailing Address - Fax:
Practice Address - Street 1:14850 ROSCOE BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4618
Practice Address - Country:US
Practice Address - Phone:626-394-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41346106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist