Provider Demographics
NPI:1396983748
Name:LERACH, SHANNON (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:LERACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 N HIGHWAY 101
Mailing Address - Street 2:SUITE 16
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1180
Mailing Address - Country:US
Mailing Address - Phone:619-817-5320
Mailing Address - Fax:858-481-1674
Practice Address - Street 1:243 N HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1180
Practice Address - Country:US
Practice Address - Phone:619-817-5320
Practice Address - Fax:858-481-1674
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 23705103TF0000X, 103TC2200X
CAPSY23705103TF0200X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling