Provider Demographics
NPI:1306393269
Name:FORSYTHE, SHAUNA J
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:J
Last Name:FORSYTHE
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 1:111 N MARKET ST STE 950
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95113-1112
Mailing Address - Country:US
Mailing Address - Phone:347-933-8284
Mailing Address - Fax:
Practice Address - Street 1:111 N MARKET ST STE 950
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95113-1112
Practice Address - Country:US
Practice Address - Phone:347-933-8284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF93891106H00000X
CALMFT111445106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist