Provider Demographics
NPI:1356857387
Name:SHIN, EDWARD JONGEUN
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JONGEUN
Last Name:SHIN
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 1:136 N LOHRUM LN
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-3114
Mailing Address - Country:US
Mailing Address - Phone:951-955-7320
Mailing Address - Fax:951-955-7203
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:SUITE 2002
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507
Practice Address - Country:US
Practice Address - Phone:951-955-7320
Practice Address - Fax:951-955-7203
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40646106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty