Provider Demographics
NPI:1710052048
Name:CHESTNUT, SHANE T (BA)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:T
Last Name:CHESTNUT
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 CASSIDY ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-5314
Mailing Address - Country:US
Mailing Address - Phone:760-721-2171
Mailing Address - Fax:760-721-8582
Practice Address - Street 1:321 CASSIDY ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5314
Practice Address - Country:US
Practice Address - Phone:760-721-2171
Practice Address - Fax:760-721-8582
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health