Provider Demographics
NPI:1972626521
Name:PETERSON, SHANNON SHAFFER (MS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SHAFFER
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12851 HASTER ST APT 11D
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-6560
Mailing Address - Country:US
Mailing Address - Phone:714-349-9063
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR STE 401
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3506
Practice Address - Country:US
Practice Address - Phone:866-830-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98637106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist