Provider Demographics
NPI:1609393958
Name:TAL, SHANNI (PSYD)
Entity Type:Individual
Prefix:
First Name:SHANNI
Middle Name:
Last Name:TAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 CAMINO DEL RIO S STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3609
Mailing Address - Country:US
Mailing Address - Phone:619-275-2286
Mailing Address - Fax:
Practice Address - Street 1:2221 CAMINO DEL RIO S STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3609
Practice Address - Country:US
Practice Address - Phone:619-275-2286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CAPSY34230103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program