Provider Demographics
NPI:1790489433
Name:MOSQUEDA, SHANNEN ISABELLE PONCE (ASW)
Entity Type:Individual
Prefix:
First Name:SHANNEN ISABELLE
Middle Name:PONCE
Last Name:MOSQUEDA
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1588 W RENE DR
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-1353
Mailing Address - Country:US
Mailing Address - Phone:714-348-4530
Mailing Address - Fax:
Practice Address - Street 1:1588 W RENE DR
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-1353
Practice Address - Country:US
Practice Address - Phone:714-348-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85901261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)