Provider Demographics
NPI:1740586338
Name:ROBERSON, SHONA
Entity Type:Individual
Prefix:
First Name:SHONA
Middle Name:
Last Name:ROBERSON
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 1:867 N FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3083
Mailing Address - Country:US
Mailing Address - Phone:626-798-6793
Mailing Address - Fax:
Practice Address - Street 1:867 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-3083
Practice Address - Country:US
Practice Address - Phone:626-798-6793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 64833106H00000X
CA84932106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist