Provider Demographics
NPI:1679233779
Name:NATIVIDAD SAN JUAN, SHARA
Entity Type:Individual
Prefix:
First Name:SHARA
Middle Name:
Last Name:NATIVIDAD SAN JUAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHARA
Other - Middle Name:
Other - Last Name:SAN JUAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2400 PROFESSIONAL PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 PROFESSIONAL PKWY STE 150
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1635
Practice Address - Country:US
Practice Address - Phone:805-608-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician