Provider Demographics
NPI:1841315835
Name:BURKE, SHANNON MICHELE (MFT)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:MICHELE
Last Name:BURKE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 SEAFARER ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-4253
Mailing Address - Country:US
Mailing Address - Phone:805-901-4633
Mailing Address - Fax:
Practice Address - Street 1:1911 WILLIAMS DR STE 150
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2612
Practice Address - Country:US
Practice Address - Phone:805-981-8483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 35607106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist