Provider Demographics
NPI:1922772433
Name:STORM, SHYLA
Entity Type:Individual
Prefix:
First Name:SHYLA
Middle Name:
Last Name:STORM
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 1:1989 VICENTE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6863
Mailing Address - Country:US
Mailing Address - Phone:805-781-4179
Mailing Address - Fax:
Practice Address - Street 1:1989 VICENTE DR
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6863
Practice Address - Country:US
Practice Address - Phone:805-781-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-07
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA136448106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program