Provider Demographics
NPI:1790244135
Name:FAUST, SHANNAN A
Entity Type:Individual
Prefix:MS
First Name:SHANNAN
Middle Name:A
Last Name:FAUST
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 1:470 E 3RD ST STE C
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1630
Mailing Address - Country:US
Mailing Address - Phone:213-620-5712
Mailing Address - Fax:
Practice Address - Street 1:470 E 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013
Practice Address - Country:US
Practice Address - Phone:213-620-5712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC6920101YM0800X
106S00000X
CA11912101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician