Provider Demographics
NPI:1770791881
Name:SHEA, SHOSHANA (PHD)
Entity type:Individual
Prefix:DR
First Name:SHOSHANA
Middle Name:
Last Name:SHEA
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 1:1750 KETTNER BLVD
Mailing Address - Street 2:UNIT 204
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2531
Mailing Address - Country:US
Mailing Address - Phone:619-269-2655
Mailing Address - Fax:
Practice Address - Street 1:3252 HOLIDAY CT
Practice Address - Street 2:SUITE 209
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-0027
Practice Address - Country:US
Practice Address - Phone:619-269-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19888103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical