Provider Demographics
NPI:1255565867
Name:RYAN, SHANNON (LMFT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 MIDDLE RINCON RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3107
Mailing Address - Country:US
Mailing Address - Phone:707-909-0168
Mailing Address - Fax:
Practice Address - Street 1:540 MIDDLE RINCON RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-3107
Practice Address - Country:US
Practice Address - Phone:707-909-0168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44076106H00000X
NV01154106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV01154OtherNV BOARD OF MARRIAGE AND FAMILY THERAPIST
CA44076OtherSTATE LICENSE