Provider Demographics
NPI:1891328688
Name:SPAIN, SHANNAH
Entity Type:Individual
Prefix:
First Name:SHANNAH
Middle Name:
Last Name:SPAIN
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 1:8910 CLAIREMONT MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1104
Mailing Address - Country:US
Mailing Address - Phone:619-922-8071
Mailing Address - Fax:
Practice Address - Street 1:8910 CLAIREMONT MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1104
Practice Address - Country:US
Practice Address - Phone:858-514-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty