Provider Demographics
NPI:1770032674
Name:BATES, SHANNON (LMFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 TAYLOR PL
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 LOS OSOS VALLEY RD STE C
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-3268
Practice Address - Country:US
Practice Address - Phone:805-704-4724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119590106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist