Provider Demographics
NPI:1659501203
Name:BREWSTER, SHANNON E (LVN)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:E
Last Name:BREWSTER
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23288 WILD HORSE CT
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10001 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3507
Practice Address - Country:US
Practice Address - Phone:951-343-2536
Practice Address - Fax:951-729-3309
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN208396101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor