Provider Demographics
NPI:1780646729
Name:WHYTE, SHANNON RENEE (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:WHYTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 KINGSTON DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4003
Mailing Address - Country:US
Mailing Address - Phone:972-480-0663
Mailing Address - Fax:
Practice Address - Street 1:4715 VIEWRIDGE AVE STE 230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1680
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32532103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C9712Medicare ID - Type Unspecified
Q31203Medicare UPIN