Provider Demographics
NPI:1710350632
Name:WHITE, SHANNON MARIE (RAS II, CATC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:RAS II, CATC
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:NUTTING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RAS II, CATC
Mailing Address - Street 1:234 N MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3906
Mailing Address - Country:US
Mailing Address - Phone:619-579-8373
Mailing Address - Fax:
Practice Address - Street 1:234 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3906
Practice Address - Country:US
Practice Address - Phone:619-579-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN0810131730101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)