Provider Demographics
NPI:1447768668
Name:THOMAS, SHANNON MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:LEINERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:11037 WARNER AVE # 339
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4007
Mailing Address - Country:US
Mailing Address - Phone:800-273-4292
Mailing Address - Fax:949-253-4627
Practice Address - Street 1:2535 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3754
Practice Address - Country:US
Practice Address - Phone:800-273-4292
Practice Address - Fax:949-253-4627
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-31036103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst