Provider Demographics
NPI:1740776913
Name:SHIN, MINJUNG
Entity Type:Individual
Prefix:
First Name:MINJUNG
Middle Name:
Last Name:SHIN
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 1:3000 LILLARD DR APT 187
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4872
Mailing Address - Country:US
Mailing Address - Phone:661-476-7987
Mailing Address - Fax:
Practice Address - Street 1:1446 ETHAN WAY STE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2214
Practice Address - Country:US
Practice Address - Phone:209-667-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician