Provider Demographics
NPI:1639828049
Name:ANDERSON, SHEENA RENEA
Entity Type:Individual
Prefix:
First Name:SHEENA
Middle Name:RENEA
Last Name:ANDERSON
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 1:510 HIBISCUS DR APT D101
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6157
Mailing Address - Country:US
Mailing Address - Phone:760-701-7746
Mailing Address - Fax:
Practice Address - Street 1:24081 SANDY GLADE AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-5529
Practice Address - Country:US
Practice Address - Phone:951-525-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT-02212289246RP1900X
251E00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No251E00000XAgenciesHome Health