Provider Demographics
NPI:1588844393
Name:DAWSON, SHUNTAE (MFT)
Entity Type:Individual
Prefix:
First Name:SHUNTAE
Middle Name:
Last Name:DAWSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:
Other - Last Name:DAWSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:107 DARCY PKWY
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-9219
Mailing Address - Country:US
Mailing Address - Phone:209-808-6892
Mailing Address - Fax:
Practice Address - Street 1:107 DARCY PKWY
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-9219
Practice Address - Country:US
Practice Address - Phone:209-808-6892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51414101YM0800X, 101YP2500X, 101YA0400X, 101Y00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor