Provider Demographics
NPI:1407345531
Name:VONG, SHANNEN (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNEN
Middle Name:
Last Name:VONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HARPST ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-8222
Mailing Address - Country:US
Mailing Address - Phone:707-826-3236
Mailing Address - Fax:
Practice Address - Street 1:1 HARPST ST FL 2
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-8222
Practice Address - Country:US
Practice Address - Phone:707-826-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30027103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical