Provider Demographics
NPI:1568894038
Name:WEISBERG, SHANNON (MFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WEISBERG
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 GREEN GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-4018
Mailing Address - Country:US
Mailing Address - Phone:415-389-1952
Mailing Address - Fax:
Practice Address - Street 1:645 TAMALPAIS DR STE D
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1613
Practice Address - Country:US
Practice Address - Phone:415-250-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA95759106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program