Provider Demographics
NPI:1003487778
Name:SHAO, STEPHANIE SI-YU (LCSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SI-YU
Last Name:SHAO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 SAXONY RD STE 111
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6779
Mailing Address - Country:US
Mailing Address - Phone:760-278-8934
Mailing Address - Fax:
Practice Address - Street 1:169 SAXONY RD STE 111
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6779
Practice Address - Country:US
Practice Address - Phone:760-278-8934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2024-12-03
Deactivation Date:2023-07-11
Deactivation Code:
Reactivation Date:2023-10-17
Provider Licenses
StateLicense IDTaxonomies
DCLC2000032881041C0700X
CA1274531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical