Provider Demographics
NPI:1427396712
Name:ANDERSON, SHANNAE (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNAE
Middle Name:
Last Name:ANDERSON
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 1:325 E HILLCREST DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-5828
Mailing Address - Country:US
Mailing Address - Phone:805-496-7144
Mailing Address - Fax:
Practice Address - Street 1:325 E HILLCREST DR
Practice Address - Street 2:SUITE 207
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5828
Practice Address - Country:US
Practice Address - Phone:805-496-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16498103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist