Provider Demographics
NPI:1831618784
Name:CAMPANA, SHYANN MIKAELL (MA)
Entity type:Individual
Prefix:
First Name:SHYANN
Middle Name:MIKAELL
Last Name:CAMPANA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8350 N CENTRAL EXPY STE 1275
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1614
Mailing Address - Country:US
Mailing Address - Phone:469-232-7965
Mailing Address - Fax:
Practice Address - Street 1:8350 N CENTRAL EXPY STE 1275
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-1614
Practice Address - Country:US
Practice Address - Phone:469-232-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA6103T00000X
390200000X, 103T00000X
TX38721103T00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX38721OtherLICENSED PSYCHOLOGIST NUMBER