Provider Demographics
NPI:1891497285
Name:BLEVINS, SHAWNTAL RENEE
Entity Type:Individual
Prefix:
First Name:SHAWNTAL
Middle Name:RENEE
Last Name:BLEVINS
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 1:1080 MARINA VILLAGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403
Mailing Address - Country:US
Mailing Address - Phone:650-539-0340
Mailing Address - Fax:
Practice Address - Street 1:1080 MARINA VILLAGE PARKWAY
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403
Practice Address - Country:US
Practice Address - Phone:650-539-0340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health