Provider Demographics
NPI:1740041656
Name:CHA, SHELBY ANDRA-FAVERO
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:ANDRA-FAVERO
Last Name:CHA
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 1:720 N GARFIELD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-4200
Mailing Address - Country:US
Mailing Address - Phone:406-839-6681
Mailing Address - Fax:
Practice Address - Street 1:30 N RAYMOND AVE STE 604
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-4445
Practice Address - Country:US
Practice Address - Phone:406-839-6681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138494106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist