Provider Demographics
NPI:1245880087
Name:IZADI, SHANETTE MICHELLE
Entity type:Individual
Prefix:MISS
First Name:SHANETTE
Middle Name:MICHELLE
Last Name:IZADI
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 1:3446 SONYA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSAMOND
Mailing Address - State:CA
Mailing Address - Zip Code:93560-6831
Mailing Address - Country:US
Mailing Address - Phone:626-662-3233
Mailing Address - Fax:
Practice Address - Street 1:176 HOLSTON DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4531
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 101YM0800X
CA971501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical