Provider Demographics
NPI:1902357189
Name:BEAUCHAMP, SHANNON LEE (CADCII, ICADC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:BEAUCHAMP
Suffix:
Gender:F
Credentials:CADCII, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 VIA LIDO
Mailing Address - Street 2:STE. 241
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3908
Mailing Address - Country:US
Mailing Address - Phone:619-715-9408
Mailing Address - Fax:
Practice Address - Street 1:3101 W COAST HWY
Practice Address - Street 2:STE. 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4001
Practice Address - Country:US
Practice Address - Phone:619-715-9408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA021560216101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1790133346OtherNPI