Provider Demographics
NPI:1902125735
Name:POPPITO, SHANNON ROSE
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ROSE
Last Name:POPPITO
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 1:1500 DUARTE RD
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-3012
Mailing Address - Country:US
Mailing Address - Phone:646-853-4376
Mailing Address - Fax:626-256-8798
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:646-853-4376
Practice Address - Fax:626-256-8798
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 23441103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical