Provider Demographics
NPI:1407165285
Name:SAMPSON, SHANNON ELIZABETH (MA)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 BALBOA AVE
Mailing Address - Street 2:SUITE 803
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6906
Mailing Address - Country:US
Mailing Address - Phone:858-255-1452
Mailing Address - Fax:
Practice Address - Street 1:5252 BALBOA AVE
Practice Address - Street 2:SUITE 803
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6906
Practice Address - Country:US
Practice Address - Phone:858-255-1452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2012-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1339106H00000X
CA51965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist