Provider Demographics
NPI:1013356229
Name:KLOSAK, SHANNON (LMFT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KLOSAK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:KLOSAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CATC-IV
Mailing Address - Street 1:324 E BIXBY RD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3432
Mailing Address - Country:US
Mailing Address - Phone:562-595-8111
Mailing Address - Fax:562-595-8148
Practice Address - Street 1:324 E BIXBY RD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3432
Practice Address - Country:US
Practice Address - Phone:562-595-8111
Practice Address - Fax:562-595-8148
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT93637106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist