Provider Demographics
NPI:1639908841
Name:POPP, SHELBY ANN
Entity type:Individual
Prefix:MS
First Name:SHELBY
Middle Name:ANN
Last Name:POPP
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 1:8735 CROCKETT ST
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3226
Mailing Address - Country:US
Mailing Address - Phone:619-961-7556
Mailing Address - Fax:
Practice Address - Street 1:3878 RUFFIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1842
Practice Address - Country:US
Practice Address - Phone:619-795-9935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB1135622106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician