Provider Demographics
NPI:1578341236
Name:BISHOP, SHANTE L
Entity Type:Individual
Prefix:
First Name:SHANTE
Middle Name:L
Last Name:BISHOP
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 1:5655 HERMOSILLA AVE
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-2735
Mailing Address - Country:US
Mailing Address - Phone:805-712-5879
Mailing Address - Fax:
Practice Address - Street 1:4051 BROAD ST STE 110
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8722
Practice Address - Country:US
Practice Address - Phone:805-242-1617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician