Provider Demographics
NPI:1932988995
Name:ELLIS, SHANNON MARIE (RADT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16408 SIERRA HWY SPC 21
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-1499
Mailing Address - Country:US
Mailing Address - Phone:661-388-1674
Mailing Address - Fax:
Practice Address - Street 1:8140 SUNLAND BLVD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-3948
Practice Address - Country:US
Practice Address - Phone:818-582-8832
Practice Address - Fax:818-582-8836
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)