Provider Demographics
NPI:1710570676
Name:GENSAW, SHOSHONI LEE VIOLA (MA)
Entity Type:Individual
Prefix:
First Name:SHOSHONI
Middle Name:LEE VIOLA
Last Name:GENSAW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 782
Mailing Address - Street 2:
Mailing Address - City:HOOPA
Mailing Address - State:CA
Mailing Address - Zip Code:95546-0782
Mailing Address - Country:US
Mailing Address - Phone:170-749-9257
Mailing Address - Fax:
Practice Address - Street 1:1560 BETTY CT
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-4178
Practice Address - Country:US
Practice Address - Phone:170-749-9257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123921101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health