Provider Demographics
NPI:1568872026
Name:EDWARDS, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:EDWARDS
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 1:17830 ARROW BLVD
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-4037
Mailing Address - Country:US
Mailing Address - Phone:909-356-6485
Mailing Address - Fax:
Practice Address - Street 1:1330 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3905
Practice Address - Country:US
Practice Address - Phone:909-463-5042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health