Provider Demographics
NPI:1497092977
Name:OTAWKA, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:OTAWKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18700 MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1714
Mailing Address - Country:US
Mailing Address - Phone:949-447-1154
Mailing Address - Fax:
Practice Address - Street 1:18700 MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1714
Practice Address - Country:US
Practice Address - Phone:949-447-1154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111859106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist